Authorization to Make Medical Decisions for Minor
Information & Instructions
What is the purpose of the Authorization to Make Medical Decisions for Minor?
This form allows you, as the parent or legal guardian, to temporarily appoint another individual as your Agent, to make
health care decisions for the child. The appointment lasts only up to 60 days, and is intended for situations such as
when a parent is temporarily out of state and the minor child is remaining with a family member or family friend.
What will the appointed agent be able to do?
Once this form is completed, the Agent will be able to make health care decisions for the minor child, on the parent
or legal guardian’s behalf. The Agent can consent to medical treatment. This form does not authorize the Agent broad
rights to access the minor child’s medical record. You do have the opportunity to limit the Agent’s authority, by setting
forth any specific acts you do not want the Agent to perform in the appropriate section of the form..
What steps must I take to complete the form?
Provide the information requested, including setting forth the limit on the Agent’s authority, if any. Your signature at
the end of this section certifies that you have the legal right to make this appointment (in other words, that there is no
court order prohibiting you from doing so).
Section 2: You must have two witnesses sign and date the form, and print their name, address and telephone number.
The witnesses must be over age 18, and neither witness can be the individual identified as the Agent.
FORM # 51659 (3/12) POD