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McKIMMEY LAW OFFICE, P.C.
24 E. Highland
Shawnee, Oklahoma 74801
Telephone: 405-275-3564
Fax: 405-225-7635

E-mail: legalsite@yahoo.com

MEDICAL AUTHORIZATION FOR CARE OF MINOR
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This Medical Authorization Form is a limited Power of Attorney used by parent(s) to grant to another person the right to act in the place of a parent of a minor childin certain instances.
The exact powers granted are enumerated in the power of attorney, as well as the limitations upon the exercise of the power.
The person giving a power of attorney does not give up the power to exercise his or her own powers, nor give up the power to do the things he or she has granted another to do by virtue of the power of attorney.
The Powers in this Medical Authorization Form may be revoked at any time by the parent or custodian of the child.

Common Uses
When child is staying or vacationing temporarily with grandparent, relative or other person, the parent may need to grant the person having temporary custofy of the child the powers to:

Consent to Necessary Medical Care

Consent to Enrol child in School

Consent to pick child up from shool and other places

Consent to attend church or school outings.

Act as parent on other occaisions when consent of authorized person is needed.

Hospitals, Doctors, Schools, Churches and other entities are not required to honor the Medical Authorization Form.

Although any Power of Attorney may be revoked at any time by the person granting the power, fully revoking it may sometimes be difficult to do.

A hospital, medical provider, school, church or other entity that relies upon a Power of Attorney that you have executed must have actual notification that the Power of Attorney has been revoked, or it may continue to honor it.

A Power of Attorney does not grant any powers to act after the death of the person granting it, nor after the date of expiration shown on the power. It is not a substitute for probate, nor guardianship.

This Medical Authorization Power of Attorney is not a relingquishment of the rights of a parent to the child, and takes no rights away from the parent.

Generally we can prepare a Medical Authorization Power of Attorney for you from information you furnish in the form below.

We Prepare

Two Original Medical Authorization Powers of Attorney for Execution

We Also Provide

Complete instructions for the execution and use of the Medical Authorization Power of Attorney.

Our Charge for the Service is $75.00

You May Complete The Following Questionaire to Provide All of the Information We Need To Prepare Your Medical Authorization Power of Attorney.
If you have specific questions concerning your Power of Attorney, please E-Mail your questions. You should get a response by the next business day.
If more information is necessary we will send you an E-Mail requesting more specific information.

Medical Power of Attorney Questionaire

In Filling Out This Questionaire, the parties will be referred to as Custodian and Attorney.
The Custodian is the person who has legal custody of the child. Generally these would be the parents, but in the event of divorce, the custodian is the parent having legal custody by court order.
Both parents should sign the form unless one parent has been given legal custody by court order.
This must be signed before a Notary Public.
The Attorney is the person who is granted the powers to act for an in behalf of the Custodian.
This Attorney does not need to sign the instrument.

Information About The Child

Full Name of Child: -
Last 4 numbers of SS# -

Street Address of Child -

City, State & Zip Code -

Child's Phone Number -

County of Child's Residence -

Date of Birth of Child -

Birth Place of Child -

Gender of the Child - Male Female

Information About Legal Custodian No. 1

Full Name of Custodian: -
Relationship to Child ( Mother, Father, etc. ): -
Street Address of Custodian -

City, State & Zip Code -

Custodian's Phone Number -

Custodian's E-Mail -

County of Custodian's Residence -

Gender of the Custodian - Male Female

Information About Legal Custodian No. 2 If There is Only One Legal Custodian Skip This

Full Name of Custodian: -
Relationship to Child ( Mother, Father, etc. ): -
Street Address of Custodian -

City, State & Zip Code -

Custodian's Phone Number -

Custodian's E-Mail -

County of Custodian's Residence -

Gender of the Custodian - Male Female

Information About Attorney No. 1
( Person Receiving Power of Attorney )

Full Name of Attorney: -
Relationship to Child ( Grandmother, Grandfather, Friend, etc. ): -
Street Address of Attorney -

City, State & Zip Code -

Custodian's Phone Number -

Custodian's E-Mail -

County of Attorney's Residence -

Gender of the Attorney - Male Female

Information About Attorney No. 2
( Person Receiving Power of Attorney ) If There is Only One Person Receiving Power Skip This

Full Name of Attorney: -
Relationship to Child ( Grandmother, Grandfather, Friend, etc. ): -
Street Address of Attorney -

City, State & Zip Code -

Custodian's Phone Number -

Custodian's E-Mail -

County of Attorney's Residence -

Gender of the Attorney - Male Female

This Power of Attorney Expires ( Date of Expiration )
[ If No Expiration Date - Type None ]

Powers To Be Granted
( What Attorney Can Do for Child )
Consent to Medical Treatment - Yes No

Consent to Dental Treatment - Yes No

Consent to School Enrolment - Yes No

Consent to School Trips & Outings - Yes No

Consent to Church Trips & Outings - Yes No

Consent to Picking Up From School & Other Functions - Yes No

Power to File Claims For Insurance Benefits - Yes No

Power to Obtain Medical Information - Yes No

Power to Obtain School Information - Yes No

Please add any additional powers you would like to add
and comments you have below:

Send Completed Forms To:

Full Name - First, Middle, Last:

Mailing address:

Street address or P.O. Box:

City:

State or Province:

Zip or Postal Code:

County:

Telephone:

Fax:

E-mail address:

Please Scroll Page to Be Sure the Information is Correct
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