I hereby certify that I am the parent, legal guardian, or other relation legally authorized to provide healthcare-related consent for the minor child listed above. I understand I am providing consent to capture and store personal health information (PHI) necessary for diagnosis, examination, treatment, and/or procedures on behalf of this minor child. Upon request, I will provide proof of legal authority and financial responsibility in the form of,

Parent / Legal / Guardian / Legal Authority

• Birth certificate/hospital record showing this minor child’s parent(s), or
• Court-approved adoption papers (with signature or seal), or
• Court-approved letters of guardianship (with signature or seal), or
• Adoption Placement Agreement and Petition for Adoption, or
• Court child support order that shows the child’s parent(s), and

Financial Responsibility

• Most recent Tax Return showing this minor child as a dependent, (Federal or State, page one only; financial information, and the first 5 digits of Social Security numbers can be blacked out), or
• Spouse’s most recent Tax Return, if the minor child is claimed on spouse’s return, (Federal or State, page one only; financial information and the first 5 digits of Social Security numbers can be blacked out), or
• Divorce decree or court orders showing responsibilities, or
• Canceled checks showing consistent (at least eight months) pattern of support.

By checking the box below, I confirm my authority and responsibility for this minor child and accept the MyWay Health Terms and Conditions of Use.