English | Español| বাংলা | 中文 | 日本語 | ភាសាខ្មែរ | ไทย | Tiếng Việt
If you are a non-parent adult relative with whom a minor is living with , you may authorize medical care for the minor by completing and signing the “Caregiver’s Authorization Affidavit.”
Authorization for Third Party to Consent to Treatment of Minor Lacking Capacity to Consent
English | Español| বাংলা | 中文 | 日本語 | ភាសាខ្មែរ | ไทย | Tiếng Việt
As a parent or legal guardian, if you decide to have an adult not related to the minor patient present during services, you may authorize their consent by completing the “Authorization for Third Party to Consent to Treatment of Minor Lacking Capacity to Consent Form” which the adult would bring to the minors appointment.
Notice to Patient Regarding Sliding Fee Discount Program
Notice to Patient Regarding Free Interpretation and Translation Services
English | Español| বাংলা | 中文 | 日本語 | ភាសាខ្មែរ | ไทย | Tiếng Việt
We provide onsite interpreter, over-the phone, face to face and American Sign Language interpreter services at no cost for patients who are Limited English Proficient, hard-of-hearing or deaf. We also provides translation services for vital documents including the some health education materials.
Caregiver Authorization Affidavit
English | Español| বাংলা | 中文 | 日本語 | ភាសាខ្មែរ | ไทย | Tiếng Việt
If you are a non-parent adult relative with whom a minor is living with , you may authorize medical care for the minor by completing and signing the “Caregiver’s Authorization Affidavit.”
Authorization for Third Party to Consent to Treatment of Minor Lacking Capacity to Consent
English | Español| বাংলা | 中文 | 日本語 | ភាសាខ្មែរ | ไทย | Tiếng Việt
As a parent or legal guardian, if you decide to have an adult not related to the minor patient present during services, you may authorize their consent by completing the “Authorization for Third Party to Consent to Treatment of Minor Lacking Capacity to Consent Form” which the adult would bring to the minors appointment.
Notice to Patient Regarding Sliding Fee Discount Program
English | Español| বাংলা | 中文 | 日本語 | ភាសាខ្មែរ | ไทย | Tiếng Việt
We provide Sliding Fee Discount Program to all patients regardless of inability to pay. Discounts for essential services are offered depending upon family size and income.
Notice to Patient Regarding Free Interpretation and Translation Services
English | Español| বাংলা | 中文 | 日本語 | ភាសាខ្មែរ | ไทย | Tiếng Việt
We provide onsite interpreter, over-the phone, face to face and American Sign Language interpreter services at no cost for patients who are Limited English Proficient, hard-of-hearing or deaf. We also provides translation services for vital documents including the some health education materials.