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The form collects parent/guardian and authorized adult details, requests copies of valid photo ID and supporting documents, and includes a registration checklist and screening questionnaire for the child’s medical history. It also gathers immunization record and consent selections, consent to treat, assignment of benefits, privacy notice acknowledgements, and signature/date with a 14-day authorization expiration.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/3rd-party-authorization-form-authorization-to-bring-child-for-immunization-services/287950/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/3rd-party-authorization-form-authorization-to-bring-child-for-immunization-services/287950.png","ImageObject",442,249,{"name":88,"@type":89},"Jiven","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"When should this 3rd party authorization form be used?","Question",{"text":108,"@type":109},"Use it when the parent/legal guardian is unable to accompany the child(ren) to the Ravalli County Public Health Department for immunization services and authorizes another adult to bring the child.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What documents must the parent/legal guardian include?",{"text":113,"@type":109},"Complete the registration form, include a copy of the parent/legal guardian’s valid photo ID, and include a copy (front and back) of the child’s insurance card or bring the original.",{"name":115,"@type":106,"acceptedAnswer":116},"When does the authorization expire and what authorization does the authorized adult provide?",{"text":117,"@type":109},"The authorization expires 14 days from the date of signature. The authorized 3rd party adult must bring a valid photo ID to present with the authorized person at the visit.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287950,1790192432,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":76},1099513958607,"https://ap-avatar.wpscdn.com/avatar/100002390cf8733938c?x-image-process=image/resize,m_fixed,w_180,h_180&k=1778829742770036399","CHECK LIST: 3RD PARTY AUTHORIZATION FORM  \nThis form may be used if the parent/guardian is unable to accompany their child(ren) to Ravalli County Public Health Department for immunization services and are authorizing another adult to bring in their child(ren) .  \nParent/legal guardian must:  \n􀀀 Complete Registration form: Complete page 1  \n􀀀 Include a copy of a valid photo ID of the Parent/legal Guardian completing the forms  \n􀀀 Include a copy (front and back) of your child’s insurance card or bring in the original  \n􀀀 Screening Questionnaire: Complete page 3 regarding the child’s medical history, sign and date.  \n􀀀 Include current copy of your child’s immunization record or have records faxed 406-363-7540  \n􀀀 Complete and sign 3 rd Party Authorization Form  \n􀀀 The Authorized 3 rd Party Adult must bring a valid photo ID  \n􀀀 Send all of the above information with the authorized 3 rd party person presenting for the visit with your child  \nFor staff only:  \nREGISTRATION FORM  \nDATE:    \nClient Name (person receiving services):   \nLast First MI  \nOther names used:   Date of Birth : / /   (mm/dd/yyyy) Age:  Primary Doctor:  Mailing Address:   City:   County:   State:   Zip:   \nParent/Legal Guardian Information:  \n\n| Last | First | MI | DOB |\n| --- | --- | --- | --- |\n\nLast First MI DOB  \nPhone \\#:   \nAlternate phone \\#:  May we leave a detailed message on your phone? Yes  \nRelationship to client (circle): Mother  \n____  \nNo    \nFather  \n*Other:  \nIf other: Legal Guardian/Authorized Representative ( *documentation must be provided * )  \nINSURANCE INFORMATION: Please check box and provide a copy of your insurance card(s).  \n􀀀 NO INSURANCE  \n􀀀 HMK (BLUE CROSS/BLUE SHIELD)  \n􀀀 HMK+ (MEDICAID)  \n􀀀 PRIVATE INSURANCE  \nPlease select all services requested:  \n􀀀 Required vaccines to attend public school: (MMR, Varicella, DTaP/Tdap, Polio) .  \n􀀀 Required vaccines to attend daycare: (MMR, Varicella, DTaP, HIB, PCV, Hepatitis B, Polio) .  \n􀀀 Age-recommended vaccines (excluding influenza vaccine)  \n􀀀 Influenza vaccine  \n􀀀 Other    \nAcknowledgement and Consent: Please check each of the following boxes  \n􀀀 Consent to treat: I authorize RCPH to administer treatment as deemed necessary for care of the patient named above. If applicable, I certify that I am the parent or legal guardian of the patient. I also certify that no guarantee or assurance has been made as to the results that may be obtained from the treatment.  \n􀀀 Assignment of Benefits: I authorize payment of medical benefits to RCPH.  \n􀀀 Privacy Notice: I have reviewed a copy of the Notice of Privacy Practices, which provides a description of information uses and disclosures. I may request a copy of the Notice of Privacy Practices for my own records.  \nParental/legal guardian consent for RCPH outpatient Immunization clinic services:  \n􀁸 I give permission for my child/dependent to be seen by nursing staff at RCPH indicated above. I understand that RCPH will inform me of any emergency regarding my child/dependent by phoning my contact telephone listed above.  \n􀁸 We understand that I (we) will be notified by telephone (at the contact number listed below) if other services are recommended, if there are questions or clarifications about medical history including immunizations, or in the event of an adverse reaction after receiving services.  \n􀁸 ACCEPT OR DECLINE: I authorize my health care provider and local public health agency to collect and enter my child’s immunization records into the Department of Public Health and Human Services’ immunization registry (imMTrax), a confidential computer system that contains immunization records. I understand that information in the registry may be released to local health departments, as well as my health care providers to assist in my or my child’s medical care and treatment. In addition, information may be released to childcare facilities and schools in which my child is enrolled to comply with state requirements. I understand that I can revoke this aut","cbCainl8cIO7dqaL","https://ap.wps.com/l/cbCainl8cIO7dqaL","pdf",882714,7,"English","# 3rd Party Authorization Checklist\n# Registration Form\n## Parent/Legal Guardian Information\n## Insurance Information\n## Services Requested\n## Acknowledgement and Consent\n# Health Screening Checklist\n# Notice of Privacy Practices","[{\"question\":\"When should this 3rd party authorization form be used?\",\"answer\":\"Use it when the parent/legal guardian is unable to accompany the child(ren) to the Ravalli County Public Health Department for immunization services and authorizes another adult to bring the child.\"},{\"question\":\"What documents must the parent/legal guardian include?\",\"answer\":\"Complete the registration form, include a copy of the parent/legal guardian’s valid photo ID, and include a copy (front and back) of the child’s insurance card or bring the original.\"},{\"question\":\"When does the authorization expire and what authorization does the authorized adult provide?\",\"answer\":\"The authorization expires 14 days from the date of signature. The authorized 3rd party adult must bring a valid photo ID to present with the authorized person at the visit.\"}]","3rd Party Authorization Form - Authorization to Bring Child for Immunization Services | PDF",1789632915]