Parental Pre-Authorization for Minors Form

Parental Pre-Authorization for Minors

For families who have established relationships with our practice, it may be convenient to have on file prior authorization for medical care for children when a parent cannot be present for treatment. This form authorizes EAR, NOSE, AND THROAT ASSOCIATES to provide medical care or treatment to a minor who is accompanied to an office visit by an adult who is not the minor's parent or legal guardian.

Authorization

I appoint:

Address:

City:

State:

Zip:

Who is,my child's

as my proxy decision maker for consenting to the delivery of medical care for my child,

Minor's Date of Birth:

In my absence.

Limitations

Identify any limitations on the kinds of medical services for which this authorization is given. If none, state "NONE".

Identify any limitations on the time frame for which this authorization is given. If none, state "NONE".

I understand that this consent may be revoked at any time in writing to EAR, NOSE, AND THROAT ASSOCIATES.

Contact Information

If the nature of the medical care is not routine or considered urgent, please contact me (us) regarding the healthcare of my child at the following phone numbers:

Parent / Guardian Name:

Mobile Phone Number:

Daytime Phone Number:

Parent / Guardian Name:

Mobile Phone Number:

Daytime Phone Number:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of parent or legal guardian:

Relationship:

Date:

Signature of parent or legal guardian:

Relationship:

Date:

Your information will be encrypted.