Medical Authorization Template

MEDICAL AUTHORIZATION FORM

Date: Date

PATIENT INFORMATION

Patient Name: Full Name

Date of Birth: DOB

Address: Address

Phone: Phone

PERSON GRANTING AUTHORIZATION

Name: Your Name

Relationship to Patient: Parent/Guardian/Spouse/Self

Address: Address

Phone: Phone

Email: Email

AUTHORIZED PERSON

I hereby authorize Authorized Person Name to make medical decisions for Patient Name.

Authorized Person Information:

Name: Full Name

Relationship: Relationship

Address: Address

Phone: Phone

Email: Email

SCOPE OF AUTHORIZATION

This authorization grants the authorized person the ability to:

• Consent to medical examinations
• Consent to medical treatment
• Consent to surgical procedures
• Access medical records
• Receive medical information
• Make medical decisions in emergency situations
• Authorize release of medical information
• Choose healthcare providers
• Arrange medical appointments

SPECIFIC AUTHORIZATIONS

Medical Treatment Authorized:

• Routine medical care
• Emergency medical treatment
• Specific treatments, if limited

Limitations (if any):

List any specific limitations on authorization

MEDICAL INFORMATION

Primary Care Physician:

Name: Doctor Name

Phone: Phone Address: Address

Medical Conditions:

List any relevant medical conditions

Allergies:

List any allergies

Current Medications:

List current medications

Blood Type: Blood Type, if known

Insurance Information:

Provider: Insurance Company Policy Number: Policy # Group Number: Group #

EMERGENCY CONTACTS

Primary Contact:

Name: Name

Relationship: Relationship Phone: Phone

Secondary Contact:

Name: Name

Relationship: Relationship Phone: Phone

DURATION OF AUTHORIZATION

This authorization is:

• Valid from Start Date to End Date
• Valid for specific event: Event description
• Valid until revoked in writing
• Permanent

HIPAA AUTHORIZATION

I authorize healthcare providers to release medical information to the authorized person named above in compliance with applicable privacy laws.

Information to be Disclosed:

• All medical records
• Specific information: Specify
• Mental health records
• Substance abuse treatment records
• HIV/AIDS information

REVOCATION

I understand that:

• I may revoke this authorization at any time
• Revocation must be in writing
• Revocation is effective upon receipt by healthcare provider

CONSENT TO TREATMENT

I, the authorized person, agree to:

• Make medical decisions in the patient's best interest
• Follow any known wishes of the patient
• Consult with medical professionals
• Notify family members as appropriate

ACKNOWLEDGMENT

I acknowledge that:

• I am legally authorized to grant this consent
• I have read and understand this authorization
• I am acting voluntarily and without coercion
• This authorization may be relied upon by healthcare providers

PERSON GRANTING AUTHORIZATION:

Signature: _______________________

Name: Your Name

Date: _______________________

AUTHORIZED PERSON (ACCEPTANCE):

I accept this authorization and responsibility.

Signature: _______________________

Name: Authorized Person Name

Date: _______________________

WITNESSES:

Witness 1:

Signature: _______________________

Name: Name

Date: _______________________

Witness 2:

Signature: _______________________

Name: Name

Date: _______________________

NOTARIZATION (if required):

Space for notary seal and signature

FOR HEALTHCARE PROVIDER USE:

This authorization has been reviewed and accepted.

Healthcare Provider: _______________________

Facility: Facility Name

Date: _______________________