Medical Authorization Form
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1MEDICAL AUTHORIZATION FORM
We, the undersigned, and parents of
SALLY SMITH
and
JOHN
SMITH, hereby
authorize
BETTY MAPLE
or
WILLIAM
MAPLE,
maternal grandparents
of
SALLY
AND JOHN
SMITH, to authorize any and all medical treatment for
SALLY AND
JOHN
they in their discretion see fit. This includes, but is not limited to, treatment to
relieve pain.
A photocopy of this authorization shall be deemed effective as if it were an
original. This authorization shall remain in effect until
January 1,
2008.
MEDICAL INSURANCE COMPANY:
BLUE CROSS
MEDICAL INSURANCE ID or GROUP #:
ABC1234
MEDICAL INSURANCE CO. PHONE #:
555-555-5555
PEDIATRICIAN:
Dr. Jones
PEDIATRICIAN PHONE #:
555-555-5555
___________________________________
__________________
MOM SMITH
DATE
__________________________________
__________________
DAD SMITH
DATE
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Parent category: Business