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Forms/Policies
Minor Consent Form
Brown Clinic is required to protect the rights of our patients and ensure the safety of minors. Any new patient under the age of 18 must be seen in the presence of their parent and/or legal guardian. It is important that the parent/legal guardian is aware of the minor's condition or conditions, and everyone understands and follows through with the recommended treatment plan. Parents and/or legal guardians will be asked to provide identification via a valid photo ID.

An established patient (a patient known to the practice and seen within the past 12 months) under the age of 18 may be brought in for a specific visit or timeframe by a non-custodial adult if written permission is given by the parent or legal guardian, and that adult shows a valid photo ID. (See Minor Consent Form PDF) The parent or legal guardian must leave a number where they can be reached on the date of service.

A signed and witnessed consent form from the parent/legal guardian may be signed prior to the visit, allowing the minor patient to be seen without the parent/legal guardian present.

There are certain types of minors authorized to consent because of their status. Some examples are, but not limited to, married minors, minors on active duty with the U.S. Armed Forces, and minors emancipated by a court order.

Patient FormsFinancial Policy
Brown Clinic is committed to providing you with the best possible medical care; if you have special needs, we are here to work with you. The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services.
  • The total patient balance due, including any co-payment or co-insurance, is required to be paid at the time services are provided. For your convenience, we accept cash, checks, Visa, MasterCard, Discover and American Express.
  • Our office participates with a variety of insurance plans. It is your responsibility to:
    • Bring your insurance card to every visit.
    • Be prepared to pay your co-payment at each visit. Payment can be made by cash, check,or credit card.
    • For medical care not covered under insurance, the estimated payment in full is due at the time of the visit.
  • If you are unable to pay for necessary medical care, you may be eligible to participate in a payment plan. It is your responsibility to inform us of this prior to your visit. We will Brown Clinic firmly believes that a good patient/physician relationship is based upon understanding and good communications. Questions about financial arrangements should be asked prior to services provided.We will be pleased to refer you to a Brown Clinic Financial Counselor prior to scheduling you for a visit.
  • Referrals: It is your responsibility to bring any required referrals for treatment at, or prior to the visit. If you do not have the referral, your visit may be rescheduled or you may be held financially responsible.
  • If the patient is a minor (younger than 18 years) and is unaccompanied by a parent or guardian, we must have a written release/permission from the parent or guardian. The parent, guardian or unaccompanied minor is responsible for any payment due at the time of service, bringing the necessary referrals and the insurance card.
  • If you have questions about your insurance, we are happy to help you. Specific coverage issues, however, should be directed to your insurance company member services department (number is on the insurance card).
Brown Clinic firmly believes that a good patient/physician relationship is based upon understanding and good communications. Questions about financial arrangements should be asked prior to services provided.
HIPAA Notice of Privacy Practices
The HIPAA Privacy Rule requires health plans and covered health care providers to develop and distribute a notice that provides a clear, user friendly explanation of individuals rights with respect to their personal health information and the privacy practices of health plans and health care providers. View Brown Clinic's HIPPA Notice or Privacy Practices.
Health Insurance Marketplace Coverage
The health insurance Marketplace is available to assist you as you evaluate options for you and your family. Click here to review basic information about the new marketplace.
Athletic Annual Parent/Guardian Permit & History Forms
As of the 2016/2017 school year high school athletes will need to schedule an athletic wellness appointment with their provider. Prior to the exam, the forms must be completed and signed by the student's guardian.

Print Instructions
  1. Download the forms:
    Athletic Wellness Form
    History Form

  2. Print the forms.
  3. Fill out the forms.
  4. Bring the completed signed forms to your appointment.

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