"Where Compassion, Caring and Dedication Come First"

Consent For Treatment Of A Minor

I, The parent or guardian of said patient, who i.e. a minor, authorize Taghreed Maaytah, MD, PA and all persons acting as agents thereof and all physicians to whom said minor is referred for medical treatment, to furnish all forms of diagnostic, preventative and medical treatment to said minor. This consent shall remain in effect until a written revocation hereof is delivered to TLC Pediatrics of Amarillo, PA.

Acknowledgement Of Receipt Of Notice Of Privacy Practices

I acknowledge that I have read the attached copy of the TLC PEDIATRICS of Amarillo. “Notice of Privacy Practices.” This notice describes how TLC PEDIATRICS of Amarillo may use and disclose my protected health information, certain restriction on the use and disclosure of my healthcare information and rights I may have regarding my protected health information.

Authorization And Release

I authorize Taghreed Maaytah, MD, PA to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to Taghreed Maaytah, MD, PA insurance benefits otherwise payable to me.

Payment Policy

I understand that if Taghreed Maaytah, MD, PA is not contracted with my insurance carrier, I must pay in full at the time of service. I understand that my insurance carrier may pay less than the actual bill for services. I also understand that some services provided by Taghreed Maaytah, MD, PA may not be covered by my benefit plan. I agree to be responsible for payment of all services rendered. I understand that all Co-payments, Co-insurance and Deductibles are due at the time of service. I understand that any balance generated is due within 10 days of the billing day. I realize that failure to keep this account current may result in Taghreed Maaytah, MD, PA being unable to provide additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect this amount or any future outstanding balances.

New Baby

I fully understand that my newborn baby needs to be added to my insurance policy by the two week appointment. If my newborn baby has not been added to the policy I am aware that I am responsible for the office fee.

I HAVE READ AND UNDERSTAND THE INFORMATION that ATTACHED OR REFERENCED IN THIS FORM, NAMELY THE SECTIONS TILTLED: NOTICE OF PRIVACY PRACTICES, CONSENT TO TREATMENT OF A MINOR, AUTHORIZATION AND RELEASE AND PAYMENT POLICY. I AM THE PARENT OF SAID MINOR CHILD, OR THE COURT-APPOINTED GUARDIAN FOR THE PATIENT AND I AM AUTHORIZED TO ACT ON THE PATIENT’S BEHALF TO SIGN THIS RELEASE OF INFORMATION.