Free Medical Treatment Authorization Letter [Sample]

Learn how to write a medical treatment authorization letter. Use our sample medical treatment authorization letter as a template for your authorization letter.

Medical Treatment Authorization Letter sample

Name of Legal Guardian
Address of Legal Guardian
City, State, Zip Code


RE: Medical Treatment Authorization 

To Whom It May Concern:

I, Name of Legal Guardian, am the lawful guardian of the female child named below. I give permission and consent to Name, Address and Phone Number of Temporary Caregiver to authorize medical treatment for Full Name of Child and date of birth. This permission is granted from DATE and will expire on DATE.


Signature Of Legal Guardian DATE
Printed Name of Legal Guardian

Signature of Witness or Notary (if required by the state) DATE
Printed Name of Witness

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