Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.
Medical Authorization For Minor Child In Fulton
Category:
State:
Multi-State
County:
Fulton
Control #:
US-00426
Format:
Word;
Rich Text
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Using this form, you give permission to other adults to act for you, in your absence, regarding the treatment of your child. This is a legal document.These are the official forms for use in Family Court proceedings. (1) Receive service(s) without regard to age, race, color, sexual orientation, religion, marital status, sex, gender identity, national origin or sponsor. Please download and sign this form and send to your child's prior pediatrician to request your child's medical records be sent to North Fulton Pediatrics. This consent form should be taken with the child to the hospital or physician's office when the child is taken for treatment. In the additional spaces, list the name of each child, the gender, year of birth and the parent (or other adult) with whom the child lives now.