Affidavit For Consent For Health Care For A Minor printable pdf download

Information/Instructions Regarding the

Affidavit for Consent for Health Care for a Minor

1. The Affidavit for Consent for Health Care for a Minor (Affidavit) IS intended for use in

the following circumstances:

a. There is a need for medical care of any type for a minor child (under the age of

18 years); AND

b. The child is NOT your biological child (your name does not appear on their birth

certificate as father or mother), AND

c. The child is NOT your adopted child (your name does not appear on their birth

certificate as father or mother), AND

d. The child is NOT a foster child (a child who is in the legal custody of the state);

AND

e. You have been unable to get a signed medical consent form from the child’s

parent or legal guardian, and that parent or guardian is not present to give a

consent form directly to the medical provider (doctor, nurse, dentist, psychologist,

hospital, clinic, laboratory or other types of persons/facilities who perform medical

services); AND

f. The minor child has lived with you for at least six months OR the child is related

by blood or marriage to you.

2. The Affidavit is NOT intended for use when the parent or legal guardian of the child

does not want the child to have this procedure or treatment and has told you of that

decision.

3. If your name appears on the child’s birth certificate as the father or mother you have

the right to consent for medical care for your child and you do not need to complete

the Affidavit for Consent for Health Care for a Minor.

However, this right could be

affected by certain court orders. If you have been involved in any divorce, custody,

paternity, abuse or neglect proceedings you may want to check your court order, or

have an attorney to check your court order, to determine if you have any limitations

upon your ability to consent for medical care for your minor child.

4. The Department of Health and Human Resources has the responsibility to ensure

that children in foster care receive appropriate health care. In order to fulfill this

responsibility, the Department is authorized to consent to health care services. The

Department may delegate this authority to foster parents or licensed childcare

agencies that have the day-to-day contact with the child. In general, either the

Department caseworker, foster parent, or a licensed childcare agency will authorize

Affidavit For Consent For Health Care For A Minor