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Medical Treatment Authorization Form Template

Streamline consent collection with an easy-to-use template

Navigating medical authorization can be stressful without the right tools. This template helps healthcare professionals and administrators efficiently collect consent from patients for treatments, ensuring clarity and compliance. You'll benefit from quick setup, ease of use, secure data handling, and a streamlined process that enhances patient trust. Plus, this template is WCAG-aligned, ensuring accessibility for all users. Explore the live template to see how it works!

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Phone number
Email address
Home address
Preferred language
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Decision-maker full name
Decision-maker phone
Decision-maker email
Your relationship to the patient
I am the patient
Parent
Legal guardian
Spouse/partner
Adult child
Other
Please Specify:
Emergency contact full name
Emergency contact phone
Alternate phone
Relationship to patient
Parent
Legal guardian
Spouse/partner
Adult child
Sibling
Relative
Friend
Neighbor
Other
Please Specify:
List allergies (or type None)
Current medications and dosages
Ongoing medical conditions or diagnoses
Primary care physician name
Primary care physician phone
Preferred hospital or clinic
Do you have any known allergies?
Yes
No
Insurance provider name
Member ID
Group number
Do you have active health insurance?
Yes
No
I authorize the clinic and licensed medical personnel to evaluate and provide medical care to the patient named above.
Yes
No
I authorize the clinic to provide emergency treatment if, in the clinician's judgment, delay could jeopardize health.
Yes
No
I authorize the clinic to release necessary medical information for treatment, payment, and health care operations.
Yes
No
I authorize the clinic to discuss my care with the emergency contact listed above.
Yes
No
I understand some services, tests, or referrals may not be covered by the free program and I may be responsible for those costs.
Yes
No
Any limitations, special instructions, or persons not authorized to receive information
Duration of this authorization
This visit only
Up to 6 months from signature date
Up to 12 months from signature date
Until revoked in writing
Other
Please Specify:
I understand I may revoke this authorization in writing at any time except to the extent action has already been taken.
True
False
I have received or been offered the Notice of Privacy Practices (HIPAA).
Yes
No
Not applicable
Preferred contact methods for appointment reminders and follow-ups
Phone call
Text message
Email
No messages
If the patient is a minor, I certify I am the parent or legal guardian with authority to consent.
Yes
No
Signer printed full name
Signature (type your full name to sign)
Date signed
Signer role
Patient
Parent/legal guardian
Authorized representative
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a Medical Treatment Authorization Form for an article on FormCreatorAI

When to use this form

Use this form when a minor is in your care without a parent, when an adult patient wants to name a decision-maker, or when a clinic needs written consent before treatment. It fits school trips, summer camps, sports leagues, caregiving arrangements, and pre-op visits. Clear authorization speeds triage, reduces calls for verbal consent, and helps you document scope and limits. For planned procedures that require insurer approval, pair it with the Prior authorization form. During intake, you can complement it with the Patient admission and consent form to capture broader consents and notices. The result: faster care with fewer delays and fewer disputes.

Must Ask Medical Treatment Authorization Questions

  1. Whose care does this authorization cover (full legal name and date of birth)?

    This uniquely identifies the patient and prevents chart mix-ups. Matching identity details improves record accuracy and billing.

  2. Which treatments and procedures are you authorizing?

    Defining the scope clarifies what providers may do, from diagnostics to emergency interventions. It also sets limits so staff do not exceed consent.

  3. Who can make decisions on the patient's behalf (name, relationship, and contact)?

    Naming an agent or guardian speeds care when the patient is unavailable. Contact details let staff reach the right person fast.

  4. Are there any restrictions, allergies, or standing instructions we must follow?

    Safety notes, such as medication allergies or religious limits, guide appropriate care. Capturing this now reduces risk and delays.

  5. What is the effective date range, and how can you revoke this authorization?

    Clear start and end dates avoid stale or open-ended consent. If a patient later declines care, document that with an Against medical advice form.

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