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Military Family Interactive Network (“MFIN”) Consent


I hereby consent to receiving advice and guidance available through MFIN about my child.  The statements made in this Consent by me are true and correct.

I represent that I am the parent, guardian or other individual with legal authority to provide this consent.  

I acknowledge that no guarantees have been made to me regarding results of the advice or guidance by the staff of the Kennedy Krieger Institute.

I understand that the Military Family Interactive Network Program is only available to bona-fide residents of the State of Maryland.  I will advise KKI in the event that my child and I have our legal residence relocated outside the State of Maryland.  In such an event, KKI will support and assist me in locating another provider of services.  But the final choice about a new provider is mine.

Release of Protected Health Information and Communication: My child’s care depends on communication among all care providers. When necessary or requested, I understand that the Kennedy Krieger Institute may use and disclose Protected Health Information (PHI) for treatment and health care operations without my written consent.  KKI providers communicate with each other and outside providers using the most appropriate means of communication, which may include electronic or video based communication.  Although no method of communication is completely secure, KKI uses all reasonable and legally required means to maintain the privacy and security of your personal information.

HIPAA Notice of Privacy Practices: We are required by law to provide a Notice of Privacy Practices, which can be found on the KKI website.

* I acknowledge that I understand the purpose of this consent and that I understand its contents.

By typing my name and clicking “Next” below, I agree to the terms of this consent.

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