Authorization To Consent For Health Care Of Minor (Page 2 of 7) in pdf

• Make sure the potential agent is willing to follow your wishes regarding your child’s

health care

• Make sure the potential agent is aware of your child’s current health status, including

any special conditions, medications, allergies, etc.

• Make sure the potential agent knows your child’s doctor, dentist and nearest health

care facility

• Other topics to discuss include: organ donation, your attitude towards death,

religious beliefs, etc.

• Decide when you want to make the document effective through delivery to the agent,

and when you want it recorded.

3) Fill out the Authorization to Consent for the Health Care of Minor and…

Once the Form is completed, we recommend that you keep the original and you can give a copy

of the form to the agent, you child’s doctors, nearest hospital, etc. You should also present your

child’s health care agent to any important medical personnel (including but not limited to your

child’s pediatrician) to ease any transition process in the event of your absence.

You can deliver the documents to the agent immediately, or can wait and have someone else

deliver them to the agent if you are placed in detention. This decision is very important and is

something that should be discussed with your family and an attorney. If you decide to hold on

to the documents, it also is important to decide how the documents will be delivered, and by

whom. You also should discuss the documents with your children, so that they will understand

where to go if you are arrested, and who has the authority to make decisions for them.

If over time, your beliefs or attitudes in any area change, you should inform your child’s health

care agent. How well your child’s health care agent performs depends on how well you have

prepared them and how you well you stay touch with them.

4) How to Revoke a Health Care Power of Attorney for a Minor

There may come a time when you decide that you would like to revoke (cancel) your Health

Care Consent Form for a Minor. This Form may be revoked in the following ways:

• Revocation by custodial parent (a document saying you are revoking the Health

Care Consent for a Minor);

• By executing a new Health Care Consent for a Minor;

• By any other manner by which you communicate your intent to revoke the document;

• Providing an end date for the document;

• The child reaches the age of 18; or

• Termination of parental rights.

Please note: The revocation of your Health Care Consent for a Minor becomes effective only

when you contact each agent named in the document and to your child’s attending physician,

and clearly inform each of these people that the document has been revoked. You should

communicate this decision to these people in writing.

Authorization To Consent For Health Care Of Minor Page 2