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Medical Authorization Letter Examples

Medical Authorization Letter Examples

Handing over a letter of authorization for medical treatment of an individual especially if the person going to receive the treatment is a minor, is an event of huge responsibility. How to write such a letter effectively has been discussed further.
Kundan Pandey
Last Updated: Apr 29, 2018
A letter of authorization is an extremely simple but necessary legal document that is required in case of many events. It is commonly submitted to surgeons as a part of official formality before going for surgeries or operations that may have risks of failure. For instance, if you are going for a leg surgery, your surgeon will inform you about the risks associated to the failure of treatment. Not only he will inform you verbally about the risks, he will also ask you to submit a letter signed by you in which you have asked permission from the head/director of the hospital to go for the surgery, completely, on your own will. This is necessary to avoid any legal charges on the surgeon or hospital, in the event of the treatment failure.

In another case, if a child is traveling without any of the parents, it is essential for the guardian/care taker/non-parent to possess a notarized letter from the real parents in which the parents have granted permission to the non-parent to assist the child in traveling. In many countries, if you are a non-parent or even a grandparent, traveling with a child, it is essential to own a letter of authorization for medical treatment because you won't be allowed to get medical treatment for the child, unless the birth parents arrive. Now that you know how vital these permission letters are, have a look at some samples of an authorization letter in two cases.

Medical Treatment Authorization Letter for Minors
Date: -----

To Whomsoever it May Concern,

As the parent's of the minor child(ren) [name of the child(ren)], we grant permission to the bearer of this letter to travel with our child(ren) during the dates [mention the journey dates] and also look after the treatment of our son(s)/daughter(s), if it is needed under certain circumstances and if we are unable to be reached.

Father's Name: -----
Mother's Name: -----
Parent's Home Address: -----
Father's Office Address: -----, Phone: -----, Mother's Office Address:-----, Phone: -----
Personal Cell Numbers: Father -----, Mother -----
Information about the Bearer of the Letter Personal Information of the Child(ren) Traveling
Name: -----
Home Address: -----
Age: -----
Relationship with the Child(ren): -----
Office Address (if working): -----
Office Phone Number: -----
Personal Cell Number: -----,
Child(ren) Name: -----
Date of Birth: -----
School Name: -----
Medical Insurance Policy Number: -----
Insurance Company Phone Number: -----
Blood Type: -----
Any Known Medical Complications/(Allergies): -----
Family Pediatrician Name: -----
Pediatric Clinic Address: -----
Pediatric Phone: -----

In event of an urgent medical emergency, if the bearer of this letter is not present, we authorize the following people to be contacted, if even we are unable to be reached.
Person #1: Name Cell No.-----
Person #2: Name Cell No.-----

We assume full responsibility of the expenses incurred in the medical treatment of our child(ren), if required to do so.

Thanking You,

Father's Name: -----
Signature: -----

Mother's Name: -----
Signature: -----

Medical Authorization Letter for Release of Records
Peter M. Kane (Your Name)
Street Address
City, State, Zip Code


Dr. Francis T. Williams (Doctor's Name)
Street Address
City, State, Zip Code

To Whom It May Concern:

I, Peter M. Kane, hereby authorize Dr. Francis T. Williams to release to another Doctor, Mary J. Fernandez, a practicing MD, the following medical information from my personal medical records: All pathology reports, scans, vaccination records, and reports of all treatments I received from Dr. Francis T. Williams since October 31, 2008. I give my permission for this medical information to be used for the following purpose: I have been experiencing sharp pain in the lower abdomen for many days and my MD, Mary J. Fernandez wants to know about my past treatment details regarding any kidney or stomach related disorders. I do not give permission for any other use or for any further disclosure of this information by my current doctor, Mary J. Fernandez and her hospital staff, without my written consent.

Peter M. Kane
Date of Signature

By going through the above two medical authorization letter examples, you must have got some idea about writing authorization letters. The WellnessKeen article, how to write a medical treatment authorization letter will inform you more about the intricacies of these letters. Consulting an attorney or an authorized notary in case of legal matters related to such letters is always beneficial. You can also get these letters certified by authorized notaries to make them legally perfect documents.