Medical Treatment Authorization Letter Template printable pdf download

Medical Treatment Authorization Letter Template

MEDICAL TREATMENT AUTHORIZATION LETTER

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MEDICAL TREATMENT AUTHORIZATION LETTER

GUARDIAN’S NAME

GUARDIAN’S ADDRESS

GUARDIAN’ S HOME &

CONTACT INFO

Date:

To Whom It May Concern:

Our minor child(ren) ___________________________________________, will be traveling

with and under the temporary guardianship of:

Name(s): ________________________________________________________

Relationship: _____________________________________________________

Address: ________________________________________________________

During the Dates of: _______________________________________________

In case of medical emergency during our absence, please try to reach the children’s

parents/guardians first at these numbers:

Name:___________________ Relationship:____________ Phone: ____________

In the event that none of the legal guardians noted above can be reached by phone during a

medical emergency, we authorize (Names):

___________________________________________________________________

to make any medical decisions necessary to ensure proper treatment. We will assume all

expenses related to the medical care for our child(ren).

The following minors: ________________________________ are covered by a medical

insurance policy issued by: ___________________________________________

Insured Name: ____________________________ Policy ID: _________________

Insurance Company Phone: ___________________________________________

Minors’ Physician Contact Info: ________________________________________

__________________________________________________________________

Thank you.

Parent/Guardian

Medical Treatment Authorization Letter Template