Affidavit For Consent For Health Care For A Minor (Page 2 of 4) in pdf

Affidavit For Consent For Health Care For A Minor Page 2

consent to routine health care services. For non-routine health care services such as

surgery, anesthesia, or emergency medical treatment, consent should be given as

directed by the Department through its policies. Health care providers should

request and be provided a copy of the foster child’s Medical Care Authorization for

Child in Foster Care form from the child’s caseworker, foster parent, or licensed

childcare agency caseworker.

5. If your circumstances require the use of the Affidavit for Consent for Health Care for

a minor, the affidavit must be signed in the presence of a Notary Public. Your health

care provider may have a Notary Public on their staff. If there is not a Notary

available at your health care provider’s location many banks, courthouses and

government offices employ Notaries.

6. As you complete the affidavit please make sure to explain how you attempted to

notify the parent or legal guardian that the child is in need of medical care – try to

include specifics about when you talked to the parent/guardian, where you were,

how the contact was made (by phone, e-mail, in person). If you have attempted to

talk to the parent/guardian but were unable to reach them, please include

information on how and when you tried to contact the parent/guardian.

7. Take a copy of the signed affidavit to the health care provider and attach a copy of

the affidavit to any consent form used by the health care provider.

Even though

you have this Affidavit you still need to sign the provider’s consent form.

8. Please note: Signing this form does not, in any way, give you custody or legal

guardianship of this child.

It simply allows you to consent for a medical

procedure when the child’s parent or guardian is not available or is unable to

give the consent.

Affidavit For Consent For Health Care For A Minor Page 2