Be as clear and concise as possible. It is a good policy to name the specific person to receive medical attention. Your letter may also address a specific doctor or medical facility. Ask your lawyer for help writing this letter and inquire if specific wording is required.
1. Define the conditions under which you authorize medical treatment.
- I authorize Dr. Johnson or his associate to administer any medical treatment he deems necessary for my son, John Doe, and my daughters, Suzanne and Jane Doe, while I am abroad from April 10 to May 1, 2002.
- I give my consent for medical procedures to be performed on me in the event that I am rendered unable to make such a decision for myself.
- I give my permission for the leaders of Boy Scout Troop 123 to administer or obtain medical treatment they deem necessary for my son, Eric, between August 3 and August 15.
- If I am injured in any way while driving for Doe Corporation, I give my permission for emergency medical treatment deemed necessary by the paramedics or attending medical staff.
- If I require medical attention while taking flying lessons from Doe Air Service and am unable to personally communicate my wishes regarding medical care, I authorize physicians at Doe General Hospital to administer whatever medical treatment they deem necessary for my best good.
- any emergency medical treatment
- authorize Dr. Doe to
- between the dates of
- extends to emergency care only
- for the duration of
- for medical procedures to be performed by
- give my consent for
- give permission for
- hereby authorize physicians at
- if I require medical attention
- if unable to
- if rendered unable to
- in the event of an emergency
- not to extend beyond
- permission to administer to
- should medical treatment be deemed necessary by
- this authorization takes effect on
- to perform all necessary procedures
- to carry out necessary treatment
- to make such decisions for ourselves
- to communicate my wishes regarding
- under the following conditions
- whatever care is deemed necessary by
- whatever medical treatment she deems necessary
- while in the employment of
2. Appoint someone to authorize and obtain any needed medical treatment beyond emergency care. Indicate any limitation on the length of time the person can act on your authority.
- I appoint my brother, John Doe of 1600 Main Street, Springfield, Kansas, telephone 555-5555, as my legal representative in obtaining such treatment as the situation may require until I return on October 23.
- I authorize the scoutmaster, John Doe, to make medical decisions until such time as I can be notified.
- I hereby appoint my supervisor, Jane Doe, to make any decisions regarding my treatment until I am able to make such decisions on my own, or until my wife can be notified, at which time I authorize my wife to secure any medical treatment I may need.
- I give this authority to Mr. John Doe until my husband, Robert Johnson, or I can be notified, at which time we will assume the responsibility for medical care.
- I authorize Jane Doe to obtain any medical treatment I may require until my husband or I am available to make decisions.
- act as my legal representative in
- allow an official representative of Doe Corporation to
- appoint my brother, John Doe, as
- appoint John Doe to
- as the situation may require
- at which time
- authorize the aforementioned party to
- authorize the manager, John Doe
- give this authority to
- give my consent to
- hereby appoint my supervisor
- in the absence of
- in obtaining treatment
- in my spouse's absence
- make medical decisions until
- make decisions regarding my welfare
- not to exceed a period of
- secure any treatment I may need
- to authorize and obtain any medical treatment
- treatment beyond emergency care
- until my next-of-kin has been notified
- until I am able to
- until my spouse has been notified
- will be in effect from April 15, 2002, until
- will assume responsibility for
3. Close by typing your name and date and signing the letter.
- John Doe
June 28, 2002
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