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McKIMMEY LAW OFFICE, P.C.
20 E. Ninth Street
The Aldridge - Suite 137
Shawnee, Oklahoma 74801
Telephone: 405-275-3564
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.


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  • 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relies upon a Power of Attorney that you have executed must have actual notification that the Power of Attorney has been revoked, or it may continue to honor it.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.



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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.



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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 does not mean a Lawyer. It can be any legally competent adult Person mentallly and physically capable of performing the duties and powers assiged to him or her in the Power of Attorney.

The Attorney is the person who is granted the powers to act for and in behalf of the Custodian.

The Attorney does not need to sign the instrument.

A Power of Attorney cannot be given or used to authorize or justify an illegal or immoral act.




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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


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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


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


Full Name of Attorney Given Power: -

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


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


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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


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






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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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Other Services Now Offered

[ home ] [ Amortization Schedule ] [ Certificate of Incorporation ] [ Divorce - Waiver Set ]
[ Contract For Deed ] [ Deed Preparation ] [ Termination of Joint Tenancy ] [ Termination of Life Estate ]
[ Transfer on Death Deed ] [ Medical Authorization for Care of Minor ] [ Change of Name ]
[ Power of Attorney ] [ Pre-Nuptial Agreement ] [ Promissory Note ]
[ Release of Mortgage ] [ Release of Judgment ] [ Vacate Divorce Decree ]


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