forms

Children’s Minnesota Metropolitan Pediatric Specialists has consent policies that must be followed to share your child’s medical information with you and requesting organizations such as schools, daycares, etc. You can download the consent forms listed below.

Form Completion Request
Use this form to request forms for sporting events, school, daycare, asthma action plan, allergy action plan, immunization record or medication administration form requests to be sent to any facility.

  • We are required by law any time we send protected health information (PHI) to an outside facility that we must have a parent, legal guardian or legal adult child (children age 18 or older) consent form signed for eachrequest (1 request per form).
  • We do not need the forms that your daycare or school (elementary or high school) provide to you, or forms for colleges, Boy Scouts of America and HeadStart to complete theForm Completion Request.
  • You can complete this form and either drop it off, mail it or fax it to the clinic that routinely sees your child(ren).

Medical Record Release Form
Use this form if you are transferring your child(ren) out of any of our clinics, need specific records shared with a specialist that your child(ren) may be seeing, and/or if you are applying for disability benefits or other healthcare option benefits and law firms. If the child is 18 years of age or older they can sign the form themselves or they must have the 18 year old waiver which allows parents to sign for their adult children on file with us. This release cannot be used for a single form request.

Waiver for 18 year-old patients
According to Minnesota law and the HIPAA privacy rule, when patients turn 18 years old they are considered adults and parents and guardians can no longer access the patients’ medical information without your child’s written consent. Please have your child fill out this consent form if they would like to provide consent for you (or anyone else) to view their medical information.

Medical Authorization for Minors

Use this consent form to give your permission for another caregiver to temporarily authorize treatment of your child (under 18 years of age) in your absence. This form could be used if you are going to be out of town, for example, and you are designating care to someone in your absence.

Other forms: