Minor (Child) Medical Treatment Authorization Form

Updated April 21, 2022

A minor medical treatment authorization form allows a parent or guardian to select someone else to handle the primary health care decisions of their child. It is a simple one (1) page document that authorizes a third (3rd) party representative to handle any questions or requests by doctors or hospital staff in reference to the minor’s health needs.

Abortions – For a minor seeking an abortion and requiring their parent’s consent.

How to Write

Step 1 – The Parties – Download the document and submit the following information:

  • The  parent(s) and/or legal guardian(s) full name(s)
  • The minor child/children’s name(s) (If more space is needed, add the remaining children’s names on a separate sheet and attach it to this document)
  • The name of the person(s) who shall be granted permission to obtain medical for the minor child(ren)

Step 2 – Allergy Information, (if any) –

  • Enter any known allergies the child(ren) may experience, into the line provided. If more room is required, enter the possible allergies for the remaining children on the added sheet, next to or beneath the children’s names

Step 3 – Financial Responsibility and Insurance Information –

  • The parent(s) or legal guardian(s), must read the statement of agreement to financial responsibility, for any medical attention received by the child(ren)
  • Submit the name of the health, insurance carrier
  • Enter the policy or certificate number as listed on the medical card

Step 4 – Signatures and Notarization – Signatures must be applied in the presence of a notary public

  • Submit the date of signatures in mm/dd/yyyy format
  • Submit the parent(s) or legal guardian(s) signature(s)
  • The document will require the signature of one (1) witness – The witness must enter their signature in witness
  • Once the notary public has had the ability to witness the signatures, the notary shall then complete all required information, provide the notary’s signature and affix their seal, in acknowledgment.

Copies must be provided to all parties, for their personal record keeping. The original must then be given to the authorized person who shall temporarily care for the child(ren’s) medical care.