Authorization for Minor’s Medical Treatment form facilitates the grant of medical care to a child through a third party supervision other than either of the parents. This form requires notarization of the signatures of both the parents for its execution and legal standing.
The authorization offered through using the form permits medical and/or dental treatments for the child from a licensed medical practitioner. The supervising adult who receives the power to help the child during the course of the medical treatment is in charge of the well-being of the child throughout the process. Make a few copies of the Authorization for Minor’s Medical Treatment and hand over them to all concerned. Specify all details truthfully and accurately, as it is critical during the emergencies.
Your Attention Please
- Furnish all particulars legibly and without error.
- Notarization of parent’s signature before Notary Public is necessary.
- Specify additional contact information if any for both the parents in the space provided for the same.
- Mention title and the name of the organization for supervising adult if applicable.
- Review the document carefully before proceeding.
Authorization for Minor’s Medical Treatment requires providing child’s name, date of birth, age, and school grade. Continue by furnishing the information of Doctor/HMO. Enter the name, address, phone number of Doctor/HMO in the respective fields. Specify the name of the health plan or name of the medical insurer followed by typing the policy number. Furnish details of allergy medications and others in the respective lines. The next line requires information about conditions for the child is receiving medical treatment. Furnish other crucial medical information if any, on the subsequent line. Continue by furnishing the particulars of the dentist’s name, address, and telephone number in the space provided for the same. Mention the name of the dental insurer, plan, and then policy number.
Authorization for Minor’s Medical Treatment
The succeeding portion of the Authorization for Minor’s Medical Treatment requires particulars of parent/s. Specify name of the parent, then address, home phone number, work phone number, cell phone number, pager, email address, and any other additional contact information if applicable. Accuracy while filling this section is of the utmost essence. Furnish particulars of the other parent in the similar manner.
Enter the name of the adult for notification in case none of the parent’s is reachable due to unforeseen reasons and/or circumstances. Provide the address, home and work phone number, cell phone and pager number, email address, and any other contact information if applicable.
The next portion Authorization and Consent of Parent/s is an undertaking and declaration by both parents. Provide the name of the supervising adult followed by the title and name of the organization if necessary in the respective spaces. Both parents must sign this Authorization for Minor’s Medical Treatment before the Notary Public and insert date in front of both signatures.
The last portion of the Authorization for Minor’s Medical Treatment has space reserved for notarization and it requires input of state and county name, date, name of the Notary Public, names of the parents, seal, signature, and date of expiry of commission.
Text Version of this Form
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Authorization for Minor’s Medical Treatment
Child
Name: ______________________________
Birthdate: ________________ Age: ________ Grade in school: ____________
Doctor (or HMO): ______________________________
Address: ______________________
______________________
Phone: ____________________
Medical insurer/health plan: ____________________ Policy no.: _________________
Allergies (medications): ______________________________
Allergies (other): ____________________________________
Conditions for which child is currently receiving treatment:
__________________________________________________________________
Other important medical information:
__________________________________________________________________
Dentist: ______________________________
Address: ______________________
______________________
Phone: ____________________
Dental insurer/plan: ___________________________ Policy no.: _________________
Parents (or Legal Guardians)
Parent 1
Name: ____________________
Address: ______________________
______________________
Home phone: ____________________ Work phone: ____________________
Cell phone or pager: ____________________ Email: ____________________
Additional Contact Information: ___________________________
Parent 2
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Name: ____________________
Address: ______________________
______________________
Home phone: ____________________ Work phone: ____________________
Cell phone or pager: ____________________ Email: ____________________
Additional Contact Information: ___________________________
Other Adult to Notify in Case Parent(s) Cannot Be Reached
Name: ____________________
Address: ______________________
______________________
Home phone: ____________________ Work phone: ____________________
Cell phone or pager: ____________________ Email: ____________________
Additional Contact Information: ___________________________
Authorization and Consent of Parent(s) or Legal Guardian(s)
I affirm that I have legal custody of the minor child indicated above. I give my
authorization and consent for __________________________ [name of supervising
adult], who is a(n) _____________ [title and name of organization, if appropriate], to
authorize necessary medical or dental care for my child. Such medical treatment shall be
provided upon the advice of and supervised by any physician, surgeon, dentist, or other
medical practitioner licensed to practice in the United States.Parent 1’s signature: ___________________________________ Date: ______________
Parent 2’s signature: ___________________________________ Date: ______________
Certificate of Acknowledgment of Notary Public
State of _______________________________ )
) ss
County of _____________________________ )
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On _____________________, before me, ______________________________, a notary
public in and for said state, personally appeared ___________________
________________________, personally known to me (or proved to me on the basis of
satisfactory evidence) to be the person whose name is subscribed to the within
instrument, and acknowledged to me that he or she executed the same in his or her
authorized capacity and that by his or her signature on the instrument, the person, or the
entity upon behalf of which the person acted, executed the instrument.WITNESS my hand and official seal.
_____________________________________
Notary Public for the State of ______________
My commission expires __________________
[NOTARY SEAL]
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