Medical Authorization Letter Template (How to Write)

A medical authorization letter is a legal document granting permission to someone other than the parent or legal guardian to authorize treatment for a child, senior citizen, or any other person mentioned in the letter. The letter is usually written if the primary caregiver is either out of town or not available to authorize treatment.

An authorization letter is, in most cases, given to a nanny, babysitter, or other regular caregivers. This is to ensure that should there be any health-related issues, the person under care shall not have to wait for medical treatment. If the temporary caregiver doesn’t have an authorization letter, then the child may have to wait until the legal guardian returns to get proper treatment. In cases where the person under care may require urgent treatment, not having an authorization letter could endanger the persons’ life.

Medical issues are of grave importance and should be treated with the utmost care. For that reason, the permission should only be granted to someone whom the legal guardian trusts. A medical authorization letter can only be issued by the lawful guardian of the person.

A medical authorization letter should be addressed to a specific doctor or hospital in which the treatment shall be sought. If you don’t know this information, then you can simply direct the letter “To Whom It May Concern.”

An authorization letter may also be required if a child is going on a school trip or is traveling with friends, and the legal guardian is not present. The letter will grant permission to the teacher, family member, or other chaperones legal authority to make medical decisions on your behalf.

Authorization Letter Writing Tips

The legal guardian should check with the child’s school or their family doctor before writing an authorization letter, to find out if they are supposed to fill or sign any forms.

The legal guardian should also check the laws to fulfill any requirements made available in their state for the authorization letter to be effective.

The primary objective of this letter is to show that you are aware and you acknowledge by authorization and giving consent to the temporary caregiver to make any medical decisions on your behalf.

The letter should contain:

  • The name of the legal guardian, address
  • The name and address of the person being authorized
  • The name and age of the concerned person
  • The reason for writing the letter and medical treatment authorization
  • Any special health issues
  • The legal guardian may also provide a list of things not allowed during treatment, i.e., the child’s relevant medical history, including any health conditions, vaccines, allergies medications, and any other relevant information.
  • Type of medical care you are authorizing
  • Parent/legal guardian’s contact information
  • The medical insurance information

Types of Medical Treatment Which can be Specified in the Letter

Some of the decisions commonly authorized to be made by temporary caregivers include:

  • Medical administration
  • Emergency medical transportation
  • Routine examination and check-ups
  • Anesthesia and any surgical procedures

Medical Authorization Letter Template

Medical Authorization letter

I, _______________, [name] being the _ [state your relationship with the child] of____________ [name of the child] authorize [name of authorized person] to pursue, attain, and accord to routine medical care and treatment, dental medical care and treatment, emergency medical care and treatment, for _______________ [name] as considered obligatory by the healthcare specialist. This letter is effective for the period when my child is under the care of _______________ [name of the care provider] and is valid until revoked by me.

Child’s Information

Full Name: _______________

Address: _______________

Date of Birth: _______________

Authorizing Party

Name: _______________

Address: _______________

Phone Number: _______________

Emergency Contact Person’s

Full Name: _______________

Address: _______________

Phone No.: _______________

Email: _______________

Child’s Health Information

Health Conditions

Allergies

Prescription Medications:

Dosage: _______________ Time: _______________

Dosage: _______________ Time: _______________

Child’s Medical Care and Insurance Information

Dentist: _______________ Phone Number: _______________

Doctor: _______________ Phone Number: _______________

Insurance Firm: _______________

Policy Number: _______________

Policy Holder’s name: _______________

Signature

Authorizing Party’s Signature

Date: _______________

Print Name: _______________

Details
File Format
  • MS Word

Frequently Asked Questions

When Should This Letter Be Used?

A medical authorization letter explicitly identifies the temporary caregivers authorized to make any medical decisions for a child in their care or any member of your family (senior citizen) in your absence, in addition to indicating which types of medical decisions the temporary caregivers are authorized to make.