PREAUTHORIZATION TO

TREAT MINORS CONSENT

Health Center__________________________

It may be more convenient to have prior authorization so that medical care may be delivered directly to minors if a parent or legal guardian cannot be present prior to treatment.  Please review the following authorization for treatment and complete the information and complete the information if you want to authorize such treatment for your minor child in advance.

AUTHORIZATION

I (we) have the legal right to preauthorize this facility to deliver medical treatment to my (our) child.  I (we) request and authorize Bassett Healthcare and Little Falls Hospital and their personnel to deliver care to my (our) child listed below.

Child’s Name:_________________________________ DOB:_______________

LIMITATIONS

Specify the types of medical service for which this authorization is given. __________________________________________________________________________________________________________________________________________________________________________________________________________________

Specify the time frame for which this authorization is given.  (Time frame not to exceed three months)

__________________________________________________________________________________________________________________________________________________________________________________________________________________

CONTACT INFORMATION

If the nature of the medical care is not routine, please try to contact me (us) regarding the health care of my (our) child at the following telephone numbers(s).  If you are unable for any reason to contact me (us), you may rely on the proxy decision maker for consent.

Parent’s Name: ________________________Parent’s Name: ____________________

Daytime Phone:________________________ Daytime Phone:____________________

Evening Phone: ________________________ Evening Phone: ___________________

Cell Phone:____________________________ Cell Phone: ______________________

 Parent or Legal Guardian                                                     Parent or Legal Guardian

 Proxy Decision Maker