Download Treatment of a Minor Consent (Parental Delegation)

Kaiser Foundation Health Plan of the Northwest • Kaiser Foundation Hospitals
Kaiser Permanente Health Alternatives
Treatment of a Minor Consent
(Parental Delegation)
I give my consent Kaiser Foundation Health Plan of the Northwest, Kaiser Foundation Hospitals, Northwest
Permanente, P.C., Physicians and Surgeons and Permanente Dental Associates and any of their subsidiaries or any
other organizations (and their successors or assignees) now or thereafter participating in the health care program
commonly known as Kaiser Permanente to provide routine or emergency medical, surgical, mental health or dental
treatment to my child.
My child's name is ________________________________________________ who is ____________ years of age.
My child's date of birth is __________________________________________ .
My child's health record number is __________________________________ .
My child is currently taking the following medications:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
My child has the following allergies:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Further, I authorize _______________________________________________________ to consent to the treatment of
my child, when I am unavailable. His/her address is ______________________________________________________
_____________________________________________________________________________________________________
and his/her telephone number is ________________________________________________________________.
I understand that this consent is given in advance of any specific diagnosis and such a diagnosis may later require
my specific informed consent before treatment can be provided.
This consent is valid for six months from the date of my signature, or until completion of series.
X _________________________________________________
Signature of Parent or Legal Guardian
_________________________________________/ ______________
Printed Name of Parent or Legal Guardian
Date/Time
____________________________________________________
Relationship to Minor
White: IP Medical Record or OP Medical Record - Scan
Yellow: Patient
Pink: Child Care Representative
Treatment of a Minor Consent
NOTE: Physicians are authorized by law to treat emergencies as well as other protected treatments
without written consent. See policy below for laws specific to Oregon and Washington.
1. State of Oregon
a. Consent is not needed for an emancipated minor. In Oregon an emancipated minor is anyone
who is married OR a person declared by the courts as an emancipated minor.
b. The physician/designee should attempt to contact the parent before any treatment of a minor
not protected by law (see c. below), regardless of the absence or presence of a written consent.
c. Minors treatments protected by law, that do not require parental consent are:
Sexually transmitted disease
HIV testing
Contraception advice and treatment
Pregnancy care/abortion at or above the age of 15
General medical treatment problems at or above the age of 15
Mental Health at or above the age of 14 may give permission for outpatient mental health
services without parental consent. But, parents must become involved before treatment ends
unless the parent refuses to become involved or it is not clinically indicated.
Outpatient Drug/Alcohol at or above the age of 14
Child Abuse Assessment Services
Donation of Blood age 16
2. State of Washington
a. Consent is not needed for an individual who is 18 years of age or older.
b. Consent is not needed by a minor who is married to anyone 18 years or older.
c. Consent is not needed for treatment of a minor for:
Sexually transmitted disease at or above the age of 14 and contraception advice and treatment
Mental Health at or above the age of 13 (For inpatient mental health services parents must be
notified of admission within 24 hours.)
Outpatient Alcohol/Drug Treatment at or above the age of 13
HIV testing at or above the age of 14
Child Abuse Assessment Services
General outpatient medical treatment at or above the age of 13
11551 5/12 HIM Committee
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