AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

PLEASE TYPE OR PRINT

If my child _______________________________________, date of birth __________________,

If my child _______________________________________, date of birth __________________,

If my child _______________________________________, date of birth __________________,

        month/day/year

becomes ill or involved in an accident and I cannot be contacted, I authorize the following hospital or Health Provider to give the emergency medical treatment required:

Hospital: ________________________________________________________________

Address: ________________________________________________________________

or:

Health Provider: _____________________________ Telephone No.: ________________

                                                                 M.D./N.P.

                                                                              (Area Code)

Address: ________________________________________________________________

I give permission to ____________________________________________________, located at

                                                                             Name of Facility or Caretaker

________________________________________________, to take my child(ren) for treatment.

I accept responsibility for any necessary expense incurred in the medical treatment of my child(ren), which is not covered by the following:

Health Insurance Company: _________________________________________________

Name of Policy Holder: ___________________ Relationship to Child(ren): ___________

Policy Number: ______________________ Medicaid Number: _____________________

Coverage: _______________________________________________________________

Child(ren)'s Known Allergies or Health Conditions:

Yes  _____     No _____

If yes, explain here: ______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Home Address: _________________________________________________________________

Street

City/State

Zip Code

Area Code/Telephone No.:  _________________     _________________     _________________

Home                                                Business                                    Pager/Cell Phone

Signature: _____________________________________________________________________

Relationship to Child(ren): ___________________________________Date: ________________

                                                                                                                   month/day/year