Fillable Medical Authorization Form printable pdf download

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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Medical Authorization Form

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