Medical Authorization Form

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Medical Authorization Form
Participant Information
Firs Name ________________ Middle Name ______________ Last Name_________________
Address ______________________________________________________________________
City: ____________________ Zip Code: _________________ State: ____________________
Country: __________________ Phone Number: _______________________
Date of Birth: ____________________
Medical Authorization
I authorize the employer to accord the above named person any necessary medical attention
including hospital and medical facility permissions on my behalf in case of an emergency. The
named person is covered by the health and insurance covers listed below which provide
coverage for emergency situations:
Policy Number _______________________________________________
Medical Information
Allergies: _____________________________________________________________________
Known medical conditions
Telephone contact in case of an emergency ______________________________________
Participant’s Signature: _________________________ Date: _______________
Witness’s Signature: __________________________ Date: _______________
Parent / Guardian's signature (if under 18) _______________________ Date: _______________
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Parent category: Business