To submit this form, please return it to the child's healthcare provider via email at info@healthcareprovider.com or fax it to (555) 123-4567. You may also hand deliver it to your family physician's office. For convenience, ensure all fields are completed accurately before submission. It's advisable to keep a copy of the submitted form for your records.

There are no specific important dates associated with this form, but it's advisable to keep it updated regularly. Confirm with medical providers if they require a new authorization each year. Review the document before any planned absence to ensure all information is current.

The purpose of this form is to ensure that children receive timely medical treatment when parents or guardians cannot be present. It legally empowers trusted adults to make healthcare decisions in emergencies. By completing this authorization, parents can ensure their child's well-being in unforeseen circumstances.

• 1. Patient Name: The name of the minor needing medical treatment.
• 2. Patient MRN: The Medical Record Number for identification.
• 3. Birthdate: The minor's date of birth.
• 4. Allergies, Special Conditions, or Medications: Any health concerns to inform medical providers.
• 5. Authorized Adult Information: Names, addresses, and telephone of individuals authorized to make decisions.
• 6. Parent/Guardian Signatures: Recognition and consent of the parent or guardian.
• 7. Witness Signature: Signature of an adult witness to confirm the authorization.
• 8. Insurance Information: Details regarding the minor's healthcare coverage.
• 9. Family Physician Information: Contact information for the minor's primary healthcare provider.

If you fail to submit this form, there may be significant delays in receiving necessary medical treatment for your child. Additionally, without the proper documentation, authorized individuals may not be able to make medical decisions swiftly in emergencies.

• Delayed Treatment: Without this authorization, treatment may be postponed until a parent can provide consent.
• Legal Implications: Failing to designate authorized individuals may lead to complications during medical emergencies.
• Access Issues: In absence of this form, caregivers might lack the authority to seek urgent medical care.

• 1. Vacations or Travel: Use this form when traveling to give guardians authority over medical decisions.
• 2. School Field Trips: Required for school events where children are under the supervision of teachers.
• 3. Emergency Situations: Essential during unexpected medical emergencies when immediate decisions are necessary.
• 4. Temporary Guardianship: For situations where another adult is watching your child for a period.
• 5. Extracurricular Activities: Necessary for participation in sports or camps where supervision is provided.