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113 W. MAIN STREET CARY, IL 60013 847.639.5800 Authorization to Treat Minor Patient in Absence of Parent/Guardian Name of minor patient: DOB I certify that I am the parent and/or legal guardian of
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How to fill out authorization to treat minor
How to fill out authorization to treat minor
01
Step 1: Begin by obtaining the authorization to treat minor form from the relevant authority or organization. This form is usually available online or can be obtained in person.
02
Step 2: Fill in the minor's personal information, such as their full name, date of birth, and address. Ensure that all the information provided is accurate and up to date.
03
Step 3: Specify the name and contact information of the parent or legal guardian who is authorizing the treatment. It is important to provide their full name, address, and contact number.
04
Step 4: Clearly state the medical conditions or treatments that the minor is authorized to receive. Provide detailed information about any specific medications, procedures, or therapies that the minor may require.
05
Step 5: Indicate the duration of the authorization. Specify whether it is a one-time authorization or if it is valid for a specific period. If it is valid for a specific period, provide the start and end dates.
06
Step 6: Sign and date the authorization form. Both the parent or legal guardian and a witness should sign the form to ensure its validity. Make sure to read and understand the terms and conditions before signing.
07
Step 7: Submit the completed authorization form to the appropriate party or organization. Follow the instructions provided to ensure the form reaches the intended recipient.
08
Step 8: Keep a copy of the authorization form for your records. It is important to have a copy in case it is required for future reference or in case any disputes arise.
Who needs authorization to treat minor?
01
Parents or legal guardians of a minor child usually need an authorization to treat minor.
02
In certain cases, schools, daycare centers, or other organizations responsible for the care of minors may also require authorization to treat minor.
03
Medical professionals or healthcare providers may ask for an authorization to treat minor if the minor is not accompanied by a parent or legal guardian when seeking medical treatment.
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