Notaron does not provide legal advice. This template is general-purpose. Consult an attorney for jurisdiction-specific guidance.

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Patient's full name*

Patient's date of birth*

Authorized person's full name*

Relationship to patient*

Parent/Guardian name (if patient is minor)

What is a Medical Authorization Form?

A medical authorization form grants a designated person the authority to make healthcare decisions or access medical records for another individual.

Use when a child travels without a parent, when caring for an elderly parent, or when designating a healthcare proxy.

Some healthcare providers require notarization. Check with the specific institution.

Does a medical authorization form need to be notarized?: Some providers require it. Notarization strengthens the document and is recommended.