Free Child Medical Authorization Consent Form Template

Parental and Guardian Authorization for Minor's Medical Treatment

Patient Informed Consent Documentation

Section 1: Child and Parent or Guardian Information

Section 2: Child's Medical History Summary

Section 3: Scope of Medical Treatment Authorization

Section 4: Over-the-Counter Medication Permissions

Section 5: Epinephrine Auto-Injector Standing Order (If Applicable)

If the child has a documented severe allergy requiring an epinephrine auto-injector (such as an EpiPen), I authorize the facility's trained staff to administer the auto-injector if the child exhibits signs of anaphylaxis (difficulty breathing, throat swelling, hives with rapid pulse, or loss of consciousness), in strict accordance with the standing order provided by the child's prescribing physician. Separate written standing orders from the child's physician must be on file with this authorization. Administration of epinephrine does not replace calling emergency services (911). After any epinephrine administration, I must be notified immediately and the child must be transported to the nearest emergency department.

Section 6: Temporary Medical Guardian Delegation (Optional)

Section 7: Photography and Media Release

I authorize the facility to take photographs or video recordings of the child for the purposes of medical documentation and clinical records only. Use of the child's image for any external, commercial, or educational publication will require a separate signed media release form. I may revoke this authorization in writing at any time.

Section 8: HIPAA Authorization for Medical Records Release

I authorize the healthcare facility to release the child's protected health information (PHI) to other treating healthcare providers, my health insurance carrier for billing and claims processing, the child's school nurse or designated school health official for accommodation planning, and any emergency personnel if required for emergency treatment. This authorization does not authorize the release of PHI to any third party for commercial, marketing, or research purposes without a separate written consent.

Section 9: Financial Responsibility and Insurance Authorization

I authorize the facility to bill my health insurance carrier for all medical services rendered to the child. I understand that I am responsible for all co-payments, deductibles, and charges for services not covered by my insurance plan. If the child is uninsured or underinsured, I acknowledge responsibility for all charges.

Section 10: Limitations and Exclusions

Section 11: Parent or Guardian Authorization Statement

I certify that I am the parent, legal guardian, or legally authorized representative of the minor named above and that I have the legal authority to authorize medical treatment on the child's behalf. I certify that all information provided in this form is accurate and complete to the best of my knowledge. I understand that this authorization does not obligate the facility to provide any specific treatment and that all care will be provided based on clinical judgment and the child's best interest.

Section 12: Language Access and Interpreter Services

If English is not your primary language or if you require assistance communicating, a qualified medical interpreter is available at no cost. Please notify the facility's administrative staff before signing this document if you require language assistance.

Section 13: Copy of Authorization Acknowledgment

I acknowledge that I have been offered a signed copy of this completed authorization form for my own records. I may request an updated copy or revoke this authorization at any time by providing written notice to the facility.

Section 14: Signatures and Verification