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Authorization for Medical Treatment Letter

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					The Authorization for Medical Treatment Letter is designed to provide an individual with
a formal way to authorize medical treatment for their child/dependents in the case of an
emergency, accident, injury or any other condition requiring medical treatment. This
form also has space for the medical insurance carrier information to better expedite
treatment in case of an emergency. This form can be used by parents or other
individuals who have children or other dependents and want to authorize medical
treatment for those dependents in case of an emergency.
                                    AUTHORIZATION FOR MEDICAL TREATMENT



I hereby give consent to [Provider Name] to provide medical treatment to ______________________ in
the case of an emergency, accident, injury, or any other condition requiring medical treatment.



EMERGENCY CONTACT INFORMATION

NAME: ___________________________________                        RELATIONSHIP:_____________________________
ADDRESS:_________________________________                        CITY, STATE, ZIP CODE:_______________________
HOME PHONE:_____________________________                         CELL PHONE:_______________________________


NAME: ___________________________________                        RELATIONSHIP:_____________________________
ADDRESS:_________________________________                        CITY, STATE, ZIP CODE:_______________________
HOME PHONE:_____________________________                         CELL PHONE:_______________________________




INSURANCE INFORMATION

INSURANCE COMPANY:______________________                         POLICYHOLDER NAME:_______________________
POLICY NUMBER:___________________________                        GROUP ID:________________________________




CHILD/MINOR INFORMATION

DATE OF BIRTH:____________________________ KNOWN ALLERGIES:_________________________
KNOWN HEALTH CONDITIONS:____________________________________________________________
MEDICINES:___________________________________________________________________________
PRIMARY CLINIC:___________________________ PRIMARY DOCTOR:__________________________
ADDRESS:_________________________________ PHONE NUMBER:___________________________




Parent/Legal Guardian Signature: ____________________________                    Date: _____________________

Parent/Legal Guardian Signature: ____________________________                    Date: _____________________


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Description: The Authorization for Medical Treatment Letter is designed to provide an individual with a formal way to authorize medical treatment for their child/dependents in the case of an emergency, accident, injury or any other condition requiring medical treatment. This form also has space for the medical insurance carrier information to better expedite treatment in case of an emergency. This form can be used by parents or other individuals who have children or other dependents and want to authorize medical treatment for those dependents in case of an emergency.