Child'S Emergency Medical Authorization printable pdf download

FAMILY DAY HOMES

CHILD’S EMERGENCY MEDICAL AUTHORIZATION

(MODEL FORM)

Name of Child ________________________________________________________ Date of Birth ________________

Name of Parent(s) or Guardian _______________________________________________________________________

Home Address _________________________________________________________ Telephone _________________

Place of Mother’s Employment _______________________________________________________________________

Address ______________________________________________________________ Telephone __________________

Place of Father’s Employment ________________________________________________________________________

Address ______________________________________________________________ Telephone __________________

The parent(s)/guardian authorizes ______________________________________________________________________

Name of Licensed Provider

to obtain immediate care and consents to the hospitalization of, the performance of necessary diagnostic tests upon, the

use of surgery on, and/or the administration of drugs to his/her child if an emergency occurs when he/she cannot be

located immediately, with the following exceptions: _______________________________________________________

__________________________________________________________________________________________________

It is also understood that this agreement covers only those situations which are true emergencies and only when he/she

cannot be reached. Otherwise he/she expects to be notified immediately.

1. I/we will be responsible for payment of medical care expenses. _____Yes _____No

2. Medical treatment costs are covered by:

a. Medical Insurance:

Name of Insurance Company: __________________________________

Identification Number: ________________________________________

Group Number: ______________________________________________

b. No Insurance: ______

Child’s Physician ________________________________________________________ Telephone _______________

Address _________________________________________________________________________________________

__________________________________________________

________________________________

Signature of Parent or Guardian

Date

This form is to be kept by the licensed family day provider and is to be taken to the doctor or treatment facility in case of

emergency.

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF SOCIAL SERVICES

032-05-338/6 (1/05)

Child'S Emergency Medical Authorization