PARENTAL PREAUTHORIZATION FOR MEDICAL AND OR BEHAVIORAL HEALTH CARE TO CHILDREN

UNITED COMMUNITY HEALTH CENTER - MARIA AUXILIADORA, INC.
PARENTAL PREAUTHORIZATION FOR MEDICAL AND/OR BEHAVIORAL HEALTH CARE TO CHILDREN
For families who are ongoing patients of United Community Health Center (UCHC), it may be more convenient to have prior authorization for medical and/or behavioral health care delivered to minors without a parent having to be present during treatment. Please review the following authorization for treatment and complete the information if you want to authorize such treatment in advance.

I(we) request and authorize United Community Health Center and its personnel to deliver medical and/or behavioral health care to my (our) child listed below:
Patient Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Please try to contact me (us) regarding the healthcare of my (our) child at the following number(s):
Parent/Guardian #1 Name*

First NameLast Name
Phone (home/cell)*
Phone (work)
Parent/Guardian #2 Name

First NameLast Name
Phone (home/cell)
Phone (work)
Other

First NameLast Name
Phone (home/cell)
Phone (work)
By signing, you agree your electronic signature is the legal equivalent of your manual/handwritten signature. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.
Signature (must be VALID LEGAL NAME or this form will be invalid)*

First NameLast Name
Relationship to Patient*
Date*

MonthDayYear
Date
NOTE: If any special parental or custodial relationship (such as custody with one parent only, legal custody/guardians with no parent, etc is in place, please explain in the space below.
LEGAL DOCUMENTATION MUST BE PROVIDED (please briefly explain if special parental or custodial orders).
This form expires 1 year after signature date and can be revoked at any time by parent / guardian of patient.
Should be Empty:

PARENTAL PREAUTHORIZATION FOR MEDICAL AND/OR BEHAVIORAL HEALTH CARE TO CHILDREN