[Your Name]
[Your Address]
[City, State, ZIP Code]
[Email Address]
[Phone Number]
[Date]
[Recipient’s Name]
[Recipient’s Position]
[Healthcare Facility’s Name]
[Address]
[City, State, ZIP Code]
Subject: Healthcare Authorization for [Patient’s Name]
Dear [Recipient’s Name],
I, [Your Name], residing at [Your Address], hereby authorize [Authorized Person’s Name], residing at [Authorized Person’s Address], to make healthcare decisions for [Patient’s Name], born on [Patient’s Date of Birth], during my absence from [start date] to [end date].
This authorization includes the following permissions:
- Medical Decisions: Consent to or refuse medical treatment and procedures.
- Medical Records: Access and obtain copies of medical records and information.
- Communication: Communicate with healthcare providers and make decisions regarding [Patient’s Name]’s care and treatment.
The purpose of this authorization is to ensure that [Patient’s Name] receives timely and appropriate medical care in my absence due to [reason, e.g., travel, work commitments, health issues]. [Authorized Person’s Name] is fully informed about [Patient’s Name]’s medical history and is capable of making informed decisions.
Attached are copies of my identification, [Patient’s Name]’s medical information, and [Authorized Person’s Name]’s identification for verification purposes. Should you require any further information or have any questions, please contact me directly at [your phone number] or [your email address].
Thank you for your understanding and cooperation.
Sincerely,
[Your Name]
[Signature]
[Notary Public’s Name, Signature, and Seal (if required)]