Young Adult Confidentiality / Release Form printable pdf download

Young Adult Confidentiality / Release Form

For Patients Age 18 Years and Older

Patient Name: ___________________________

Date of Birth: ____________________________

As a legal adult, I understand that all information that I discuss with my physician will be strictly

confidential and any communications from Stepping Stone Pediatrics will be discussed with me

directly. I also understand, however, that I may wish to authorize Stepping Stone Pediatrics to speak

with my parent(s) or other guardian(s) regarding specific issues related to my medical care.

□ I herby authorize Stepping Stone Pediatrics to discuss the following information (check all that

applies):

□ Appointment scheduling

□ Medication requests/refills

□ Insurance / billing / referrals

□ Medical care/treatment/lab results with the EXCLUSION of any issues circled below

(if circled we will NOT discuss with anyone but the patient)

drug/alcohol usage, sexual health, HIV testing, AIDS testing,

mental health treatment

or _____________________________(write in other specific information).

With the individual(s) listed below:

Name: _____________________

Relationship to patient: _____________________

Name: _____________________

Relationship to patient: _____________________

□ I do NOT authorize Stepping Stone Pediatrics to discuss any issues related to my medical care with

my parents(s). Further, I understand that I must review and sign the Office Policy.

This authorization will expire once I have left Stepping Stone Pediatrics.

I understand that I may revoke this consent at any time by signing the Revocation Statement below,

however such revocation does not affect any actions taken by Stepping Stone Pediatrics before I

signed the Revocation Statement.

Patient Signature: _____________________________________ Date: __________________

REVOCATION STATEMENT:

I revoke the above authorization as of the date listed below.

Patient Signature: _____________________________________ Date: __________________

Young Adult Confidentiality / Release Form