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

By placing an X beside each of the following paragraphs I acknowledge that I have read or have had

read to me these statements:

E. General Notices:

__________

This consent form is promulgated pursuant to West Virginia Code § 49-11 et seq.

This declaration does not affect the rights of the minor’s parent, guardian or legal custodian regarding the care, custody and control

of the minor, other than with respect to health care, and does not give the caregiver legal custody of the minor. This affidavit is

valid for one year unless the minor no longer resides in the caregiver’s home. Furthermore, the minor’s parent, guardian or legal

custodian may at any time rescind this affidavit of caregiver consent for a minor’s health care by providing written notification of the

rescission to the appropriate health care professional. A person who relies in good faith on this affidavit of caregiver consent for a

minor’s health care has no obligation to conduct any further inquiry or investigation and shall not be subject to civil or criminal

liability or to professional disciplinary action because of the reliance

__________

F. Penalty for False Statement:

§49-11-9. Penalty for false statement.

A person who knowingly makes a false statement in an affidavit under this article is guilty of a misdemeanor and, upon conviction

thereof, shall be fined not more than $1,000.

__________

G. Revocation and Termination of Consent:

§49-11-6. Revocation and termination of consent.

(a) The affidavit of caregiver consent for a minor’s health care is superseded by written notification from the minor’s parent,

guardian or legal custodian to the health care professionals providing services to the minor that the affidavit has been

rescinded.

(b) The affidavit of caregiver consent for a minor’s health care is valid for one year unless the minor no longer resides in the

caregiver’s home or a parent, guardian or legal custodian revokes his or her approval by written notification to the health care

professionals providing services to the minor that the affidavit has been rescinded. If a parent, guardian or legal custodian

revokes approval, the caregiver shall notify any health care provider or health service plans with which the minor has been

involved through the caregiver.

Based upon all of the statements above, I believe that I am the person who can give a consent for the health

care for _______________________________.

Child’s Name

My signature below was given on the ______ day of _______________, 20___ in ______________________,

Date

Month

City

_______________________________, County, West Virginia.

County

_____________________________________

Signature of Caregiver

STATE OF ______________________________

COUNTY OF ____________________________ to wit:

I, _________________________________, a Notary Public of said County, do certify that

______________________________, whose name(s) are signed to the writing above bearing date on the

_______ day of _____________________, 20______, have this date acknowledged the same before me.

Given under my hand this _________ day of ______________________, 20 _____.

________________________________

Notary Public

My commission expires: ___________________________.

Affidavit For Consent For Health Care For A Minor Page 4

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