This service is available Monday through Friday from 8am to 4 pm EST. If the patient is a minor under twelve (12), the parent or legal guardian may request (sign for) the health information.Using this form, you give permission to other adults to act for you, in your absence, regarding the treatment of your child. This is a legal document. I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In. This consent form should be taken with the child to the hospital or physician's office when the child is taken for treatment. Also, the parents or guardians of a child may request access if they have consented to the health care or the care was provided in an emergency without consent.