Get Medicaid Treatment Authorization Form 2004-2024

Medical Treatment Authorization Form This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency where the minor is not accompanied by either parents or legal guardians and it may not be feasible or practical to contact them. This form should be given to the trip leader or shown to the trip leader and then carried by the designated adult. Minor Full Legal Name Home Address Date of Birth Gender FemaleMale Information for Medical Treatment Physician s Name and Location of Practice Physician s Phone if known Medical Insurer/Health Plan Policy Allergies to Medications Allergies Other Please note all conditions for which the child is currently receiving treatment Note any other significant medical information AUTHORIZATION AND CONSENT OF PARENT S OR LEGAL GUARDIAN S I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for hereafter Designated Adult to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment I authorize the Designated Adult to summon any and all professional emergency personnel to attend transport and treat the minor and to issue consent for any X-ray anesthetic blood transfusion medication or other medical diagnosis treatment or hospital care deemed advisable by and to be rendered under the general supervision of any licensed physician surgeon dentist hospital or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel* This authorization is effective through. Signed this day of 20. Parent / Legal Guardian Signature Printed Name Witness Signature Printed Name Confidential Rev* July 2004. I grant my authorization and consent for hereafter Designated Adult to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment I authorize the Designated Adult to summon any and all professional emergency personnel to attend transport and treat the minor and to issue consent for any X-ray anesthetic blood transfusion medication or other medical diagnosis treatment or hospital care deemed advisable by and to be rendered under the general supervision of any licensed physician surgeon dentist hospital or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. If the injury or illness is life threatening or in need of emergency treatment I authorize the Designated Adult to summon any and all professional emergency personnel to attend transport and treat the minor and to issue consent for any X-ray anesthetic blood transfusion medication or other medical diagnosis treatment or hospital care deemed advisable by and to be rendered under the general supervision of any licensed physician surgeon dentist hospital or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of the Designated Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel* This authorization is effective through. .