Authorize Medical Treatment

Sample Letter #1

John and Jane Doe grant permission to Eric Johnson to act on our behalf to authorize necessary medical treatment for our son, Robert, while we are traveling abroad. This authorization is effective until July 30.

NOTE: Make sure you sign and date this form!

Sample Letter #2

Enclosed is a signed medical treatment authorization form giving you authority to make decisions and seek medical treatment for John Doe, Sr. from July 15 to July 31, while I am traveling abroad. I prefer that emergency treatment be given at Doe Hospital, if possible. You can reach me by phone at 555-5555, if necessary. I appreciate your accepting this responsibility.

NOTE: Make sure you sign and date this form!

Sample Letter #3

I authorize Doe Arms nursing home to administer emergency medical care to my mother, Jane Doe, in the event that I cannot be reached. This authorization extends only to times and circumstances in which my mother is in the express care of Doe Arms, in accordance with the terms of the care contract. Any non-emergency care must be authorized by me, on a case-by-case basis.

NOTE: Make sure you sign and date this form!

Sample Letter #4

In the event that I cannot be reached, I give my permission for the Sunshine Daycare Center to authorize emergency medical treatment that a physician deems necessary for the welfare of my infant son, Eric. Sunshine Daycare is limited to authorize emergency care only. This authorization is effective through April 15, 2007.

NOTE: Make sure you sign and date this form!

Sample Letter #5

By this letter I authorize Doe Memorial Hospital to perform appropriate emergency medical care for my son, Fred Doe. For non-emergency medical care, I appoint Eric Doe as my legal representative and authorize him to make decisions regarding medical treatment for Fred should I be out of town. These authorizations are valid until I revoke them in writing.

NOTE: Make sure you sign and date this form!

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