“Care for Your Child While You’re Away”
Patient’s Name: _____________________________________ Birth date: ________________
Of __________________________ ____________________________ ____________________
(City) (County) (State)
Grant permission for the Physicians of Pediatric Associates of Southern Indiana to provide medical care as
deemed medically necessary to the above-named dependent while being cared for by the following caregivers
who are at least 21 years of age.
Authorized Persons Name Relationship to child Birth date Date this form expires
If someone who is not authorized should bring your child, please send a written note with that
person. If we have no authorization complete services may not be rendered.
Parent/Legal Guardian Signature Date