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
- 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.