Sample of a consent to treat an adolescent patient that includes a limited waiver of parental rights

Our goal is to treat you and your child with respect and provide thorough and complete care. Please let us know if you ever have questions, as we want you to be a participating partner in our adolescent's care. This document is meant to prepare you for your adolescent's visit so that you and your child can have the most productive visit possible. We specifically want to address expectations you may have for: 1) scope of the visit; 2) confidentiality issues; 3) discussion with patient regarding contraception.

As a clinic that treats adolescent patients, we may have policies that differ from those of your other physicians. As adolescents become adults, it is important to help them understand their own health care needs and make sure they are capable of maintaining their health independently. In order to fully evaluate your child as he/she moves towards adulthood, it may be necessary to ask him/her questions about past actions and potential exposures, current behavior, and family/friend dynamics. A physical exam may be necessary. The scope of the physical exam will be discussed with you and your child prior to the exam, so that any questions can be addressed.

• The right to make health care decisions concerning their children'
• The right to provide written consent for a provider to treat the child, including, but not limited to, performing physical examination or prescribing prescription drugs, or to deny such consent; and
• The right to access and review all of their children's medical records.

Studies have shown that adolescents are more likely to share important health information with providers if the adolescents are offered qualified confidentiality. Qualified confidentiality means that as providers, we will ask to have private time (without the parent present) with the child, and we will ask that the parent agree in writing that the child's confidentiality should be broken only if we have reason to believe that the child is at significant risk of harm. We always encourage our minor patients to discuss with parents/guardians any and all health information that we discuss in private; however, in the event they do not feel comfortable doing so, we believe it is important to provide this opportunity for them to receive health advice from a health care provider rather than unreliable source. In the event that your child discloses information that causes the health care provider to believe your child is at significant risk for injury or death, the health care provider will disclose this information and discuss his/her concerns directly with you.

Federal and Oklahoma law allows parents/guardians to have access to all medical records of a minor, except in limited circumstances. In order to improve the health care that our adolescent patients receive, we will ask you to waive your right to access certain portions of your child's records which will be marked "confidential" and document your waiver by signing a written consent. Your agreement not to access the records pertaining to your child generated by our providers allows our providers to assure your child that the information your child shares related to their exposure to sexual activity or other risk behaviors, including but not limited to drug and alcohol use, will be maintained in confidence. Research indicates that this assurance of confidentiality improves the health care that adolescents receive. By signing the Limited Waiver of Parental Rights and Consent to Certain Treatment of Adolescent Patient below, you agree that you will not request access to or copies of your child's confidential health information that is designated in a special section of the medical record as "confidential."

As providers, we value the independent health information provided by parents regarding their children's health. Whenever possible, we prefer that such conversations regarding the child take place with the child present. If that is not possible, we are happy to discuss your child with you separately with the understanding that we will not tell you information that the child has told us in confidence.

The state of Oklahoma has one of the highest pregnancy rates in the country. In an effort to decrease rates of unplanned pregnancies, this clinic provides information regarding preventative contraception as well as medically appropriate hormonal contraception to adolescent patients. It is our normal practice to encourage adolescent patients to discuss decisions regarding contraceptive methods with their parents/guardians. We routinely offer to make ourselves available to help a patient initiate such a discussion with a parent, if the patient or parent requests. However, in the event a patient feels uncomfortable discussing this issue with parents/guardians, we would like to be able to protect the patient against experiencing an unplanned pregnancy or sexually transmitted disease. The risks of all hormonal methods of contraception are significantly less than the health risks of pregnancy. By signing the Limited Waiver of Parental Rights and Consent to Certain Treatment of Adolescent Patient below, you consent to allowing your child to receive information about contraception as well as being provided with hormonal contraception to prevent unplanned pregnancy or to treat other medical conditions, if the patient desires such therapy and the provider determines the therapy is medically appropriate. The provider will advise the patient how to take the medication, the risks and benefits associated with taking the medication, and the potential risks associated with not taking the medication as prescribed.

Limited waiver of parental rights to access medical records related to risk behaviors, including, but not limited to, the prevention of communicable diseases, contraception, sexual activity, and drug/alcohol use

As the parent or legal guardian of _{___________________________}, a minor, I understand that I have the legal right to access and review all medical records of my child unless otherwise prohibited or provided by law or unless I am the subject of an investigation of a crime committed against my child. _{______} (initial here).

I agree that it is in the best interest of my child to have the opportunity to maintain communications with his/her health care providers within the OU Physicians Adolescent Medicine Clinic in confidence. I agree that my child's physician may deem certain medical records related to risk behaviors, including, but not limited to, prevention of communicable diseases, contraception, sexual activity, and drug/alcohol use, to be confidential and agree that those records shall be marked "confidential" within the medical record. I understand that I will not be able to access or request a copy of the confidential medical records without a court order. _{______} (initial here).

Consent to physical examination and discussion outside the parent's presence

I understand that I have the legal right to make health care decisions for my child. I further understand that I have the legal right to consent in writing (or to refuse to consent) to any physical examination, procedure, or prescription drug prescribed for my child. _{______} (initial here).

I consent to my child's provider having discussions regarding risk behaviors, including but not limited to prevention of communicable diseases, contraception, sexual activity, and drug/alcohol use with my child outside of my presence so that frank and open health care advice regarding these issues can occur between the provider and my child. _{______} (initial here).

I consent to my child receiving a physical examination outside of my presence if the provider determines that it is medically indicated for the purposes of evaluating or diagnosing risk behaviors, including but not limited to the prevention of communicable diseases, contraception, sexual activity and drug/alcohol use. _{______} (initial here).

Consent to treatment

I understand that at any time upon request, I am entitled to receive a copy of the risks and benefits associated with hormonal birth control, the proper dosage and administration of the medication, and the risks of my child failing to properly take the medication. I consent to my child being provided information about hormonal contraception and receiving hormonal contraception if indicated by the provider. _{______} (initial here).

Revocation

I understand I may revoke elements of this Limited Waiver and Consent at any time by notifying staff of the Adolescent Medicine Clinic in writing. I understand any records of treatment or discussions that have already been documented in the medical record as "confidential" will remain confidential, and that this revocation will affect only treatment and discussion from the time of my notification forward.

Witnessed: _{__________________________}