Writing a Simple Medical Treatment Authorization Letter (with Sample)

Use this letter as a template for your medical treatment authorization letter.

A medical treatment authorization letter is a legal document that allows someone other than a parent or legal guardian to authorize medical treatment for a child, senior citizen or other person mentioned in the letter.

Important Document

It’s a very important document if the primary care-giver is out of town or otherwise not available to authorize treatment. In some cases, this type of letter is routinely given to a nanny, babysitter or other regular caregiver, so if the occasion arises, the child will not need to wait for medical treatment. 

In any case, a medical authorization letter should only be given to someone whom the legal guardian trusts. Authorization for medical treatment for a child or other individual can only be given by the lawful guardian of the person.

Type Of Letter

This type of letter may also be given to a specific doctor at an assisted living facility where an elderly person resides who is under the care of a legal guardian. 

This letter is usually written for an individual who is at least 18 years of age, and it is not recommended to write an authorization letter to a school or day care center because the legal guardian may not have control over which person gives authorization for treatment. If the legal guardian has a preferred local physician, a copy of the letter can be given to his or her office. 

If there are any treatments that are not acceptable to the legal guardian, these need to be mentioned in the letter. It is also recommended that the letter have an expiration date.

If a child is staying with a grandparent or other relative who is not the legal guardian, a medical authorization letter is needed. The parents should not assume that just because their child is staying with a relative, that relative can authorize medical treatment.

Temporary Caregiver

If the temporary caregiver doesn’t have written permission to authorize treatment, the child may have to wait until the legal guardian returns to get proper treatment. If the treatment is urgent this could endanger the life of the child. 

The medical treatment authorization letter should be addressed to a specific doctor or hospital where treatment will be sought. If this information isn’t known, the letter can be addressed To Whom It May Concern. The purpose of the letter should be stated in the first sentence.

Another occasion where a medial authorization letter may be needed is if a child is traveling with friends or on a school trip where the legal guardian is not present. It will give a member of the other family, a teacher or other chaperone legal permission to make medical decisions for a child.

Before Writing A Medical Authorization Letter

Before writing a medical authorization letter, the legal guardian should check with their family doctor or the child’s school to find out if there are any required forms that need to be filled out and signed by the parent or legal guardian. 

It is also recommended for the legal guardian or parent to check if there are any legal requirements in their state that need to be fulfilled in order for the authorization to be effective.

The letter must contain: • The names and addresses of the legal guardian and the person to whom the authorization is being given

• The names and birth dates of all children involved

• The purpose of the letter and giving medical treatment authorization

Some medical consent forms may contain the following points, but they are not required to create a legal document:

• The lawful guardian has no court orders that prevent him or her from conferring the power of medical authorization upon another individual.

• The guardian may give a list of treatments such as transportation by ambulance, x-rays, medication, anesthesia or others that are allowed.

• The letter may state the reason why the authorization is being given to someone else.

• The letter may state that the authorization is being given freely and not under pressure, threat, or payments from any agency.

• Any special health issues the child may have

Below are sample medical treatment authorization letters. It should be written in formal business-letter style and notarized or witnessed if required. The original can be given to the temporary caregiver, and a copy should be kept by the legal guardian.

Sample 1 – Medical Treatment Authorization Letter

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

Sample 2 – Medical Treatment Authorization Letter

Name Of Parent
Address Of Parent
City, State, Zip Code


Name Of Babysitter
Address Of Babysitter
City, State, Zip Code

RE: Authorization for Medical Treatment of Name of Child

To Whom It May Concern:

The intent of this letter is to give Name of Babysitter the authorization to take my four-year-old son Name of Son to Name of Doctor, Address of Doctor and Phone Number or Name of Hospital, Address of Hospital and Phone Number if there is a medical emergency or medical attention is required when I am not available.

Name of Babysitter is also permitted to give Name of Son OTC children’s Tylenol if he develops fever before reaching the doctor or hospital. Name of Son has no known intolerances or allergies to any medication. 

If required by the hospital or doctor, Name of Babysitter has permission to give Insurance Information. This authorization becomes invalid when Name of Babysitter is no longer in my employ. 


Parent’s Signature
Parent’s Name Printed and Relation to the Child i.e. mother, father of child
Date of signing
Copies to: Name of Hospital, Name of Doctor, Name of Babysitter, Name of Insurance Agent or Company

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