Free Medical Treatment Authorization Letter [Sample]

Template 1: Medical Treatment Authorization Letter for a Minor

[Your Name]
[Your Address]
[City, State, ZIP Code]
[Email Address]
[Phone Number]
[Date]

[Medical Facility Name]
[Address]
[City, State, ZIP Code]

To Whom It May Concern,

I, [Your Name], am the parent/legal guardian of [Minor’s Full Name], born on [Date of Birth]. I am writing this letter to grant permission and authorize medical treatment for my child in the event of a medical emergency or when I am not available to provide consent.

I understand that unforeseen circumstances may arise that require immediate medical attention, and I hereby give my full consent for the medical staff at [Medical Facility Name] to administer any necessary medical treatments, procedures, and medications to my child. 

This authorization includes, but is not limited to, hospitalization, surgery, diagnostic tests, and any other medical interventions deemed necessary by the attending medical professionals.

Additionally, I authorize the release of medical information pertaining to my child to me or any other authorized individual as required for continuity of care. This may include, but is not limited to, medical records, test results, and treatment plans.

Please find attached a copy of my identification for verification purposes.

In the event of a medical emergency involving my child, please contact me immediately at the following phone number: [Your Phone Number]. If I cannot be reached, you may contact the following alternative emergency contact:

Name: [Emergency Contact Name]
Relationship to Child: [Relationship]
Phone Number: [Emergency Contact Phone Number]

I trust that the medical professionals at [Medical Facility Name] will act in the best interest of my child’s health and well-being. Your prompt attention to this matter is appreciated.

Thank you for your cooperation.

Sincerely,

[Your Name]
(Parent/Legal Guardian)

Attachment: Copy of ID (e.g., driver’s license, passport)

Template 2: Medical Treatment Authorization Letter for Dependent Adult

[Your Name]
[Your Address]
[City, State, ZIP Code]
[Email Address]
[Phone Number]
[Date]

[Medical Facility Name]
[Address]
[City, State, ZIP Code]

To Whom It May Concern,

I, [Your Name], am the designated legal representative of [Dependent Adult’s Full Name], born on [Date of Birth]. I am writing this letter to authorize and grant consent for any necessary medical treatments and interventions required for the well-being of the dependent adult.

I understand that circumstances may arise where immediate medical attention is needed, and I hereby authorize the medical staff at [Medical Facility Name] to perform any medical procedures, administer medications, conduct diagnostic tests, and make medical decisions on behalf of the dependent adult if I am unavailable or unable to provide consent.

This authorization also includes the release of medical information to me or any other authorized individual acting in the best interest of the dependent adult. It covers medical records, test results, treatment plans, and any other relevant information required for proper medical care.

Please find attached relevant legal documents, such as a copy of the Power of Attorney or any other documentation supporting my authority to make medical decisions on behalf of the dependent adult.

In the event of a medical emergency involving the dependent adult, please contact me immediately at the following phone number: [Your Phone Number]. If I cannot be reached, you may contact the following alternative emergency contact:

Name: [Emergency Contact Name]
Relationship to Dependent Adult: [Relationship]
Phone Number: [Emergency Contact Phone Number]

I trust that the medical professionals at [Medical Facility Name] will act diligently and in the best interest of the dependent adult’s health. Your understanding and cooperation in this matter are highly appreciated.

Thank you for your attention.

Sincerely,

[Your Name]
(Designated Legal Representative)

Attachment: Relevant legal documents (e.g., Power of Attorney)

Template 3: Medical Treatment Authorization Letter for Personal Medical Procedure

[Your Name]
[Your Address]
[City, State, ZIP Code]
[Email Address]
[Phone Number]
[Date]

[Medical Facility Name]
[Address]
[City, State, ZIP Code]

To Whom It May Concern,

I, [Your Name], am writing this letter to provide my full authorization and consent for a specific medical procedure that will be performed at [Medical Facility Name]. 

I understand the nature and potential risks of the procedure and hereby authorize the medical team to perform the following medical intervention:

Medical Procedure: [Name of the Procedure]
Date of Procedure: [Date of Procedure]
Patient’s Full Name: [Patient’s Full Name]
Date of Birth: [Date of Birth]

I acknowledge that I have had the opportunity to discuss this procedure with my physician, who has addressed all my questions and concerns. I am fully aware of the potential risks and benefits associated with this medical procedure.

I voluntarily consent to the administration of anesthesia, if applicable, and any other treatment necessary for the successful completion of the procedure. 

I also authorize the medical facility to release medical information related to the procedure to my primary healthcare provider, if required for continuity of care.

Please find attached a copy of my identification for verification purposes.

I understand that while rare, unforeseen complications may arise during the procedure. In the event that my physician determines that additional treatment is necessary and time does not allow for my informed consent, I authorize my physician to take any actions deemed necessary to protect my health and well-being.

I appreciate the expertise and care of the medical staff at [Medical Facility Name], and I trust that they will conduct the procedure with the utmost professionalism and skill.

Thank you for your attention and for providing the best medical care possible.

Sincerely,

[Your Name]
(Patient’s Signature, if applicable)

Attachment: Copy of ID (e.g., driver’s license, passport)