Caretaker Authorization Affidavit Page 4
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4action or decision only by delivering written notice of negation, reversal, or disapproval to the
grandparent and the person acting on the grandparent's action or decision in reliance on this
affidavit.
To health care providers:
1. A person or entity that acts in good faith reliance on a CARETAKER AUTHORIZATION
AFFIDAVIT to provide medical, psychological, or dental treatment, without actual knowledge of
facts contrary to those stated in the affidavit, is not subject to criminal liability or to civil liability
to any person or entity, and is not subject to professional disciplinary action, solely for such
reliance if the applicable portions of the form are completed and the grandparent’s signature is
notarized.
2. The decision of a grandparent, based on a CARETAKER AUTHORIZATION AFFIDAVIT,
shall be honored by a health care facility or practitioner or educational facility or school official
unless the health care facility or practitioner or educational facility or official has actual
knowledge that a parent, guardian, or custodian of a child has made a contravening decision to
consent to or to refuse medical treatment for the child.
3. The act of a parent, guardian, or custodian of the child to negate, reverse, or otherwise disapprove
an action or decision of the grandparent who signed this affidavit constitutes termination of this
affidavit. A parent, guardian, or custodian may negate, reverse, or disapprove a grandparent’s
action or decision only by delivering written notice of negation, reversal, or disapproval to the
grandparent and the person acting on the grandparent’s action or decision in reliance on this
affidavit.
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