PREAUTHORIZATION TO TREAT MINORS CONSENT FORM

This form authorizes Bergen Ear, Nose and Throat Associates and Brian Benson, M.D. to provide medical care or treatment to a minor who is accompanied to an office visit by an adult who is not the minor’s parent or legal guardian, ex: a babysitter. The form also authorizes Bergen Ear, Nose and Throat Associates and Brian Benson, M.D. to provide such care to a sixteen or seventeen-year-old child without an accompanying adult. Please review the authorization and complete if you wish to authorize such treatment.

PREAUTHORIZATION TO TREAT MINORS CONSENT FORM

AUTHORIZATION
I appoint
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
my child’s
Specify Nature of Relationship to Minor
as my proxy decision maker for consenting to The delivery of medical care for my child
Name of Minor
First Last
Minor DOB
Date Format: MM slash DD slash YYYY
LIMITATIONS
Identify any limitations on the kinds of medical services for which this authorization is given. If none, state “None.”
Identify any limitations on the time frame for which this authorization is given. If none, state “None.”
I understand that this consent may be revoked at any time in writing to Bergen Ear, Nose and Throat Associates or Brian Benson, M.D.
CONTACT INFORMATION
If the nature of the medical care is not routine or considered urgent, please contact me (us) regarding the healthcare of my child at the following phone numbers:
Parent/Guardian Name
First Last
Parent/Guardian Name
First Last
Mobile Phone Number
Daytime Phone Number
Signature(s) of parent(s) or legal guardian(s)

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BERGEN EAR, NOSE, & THROAT ASSOCIATES, PA

PREAUTHORIZATION TO TREAT MINORS CONSENT FORM

PREAUTHORIZATION TO TREAT MINORS CONSENT FORM

AUTHORIZATION

LIMITATIONS

CONTACT INFORMATION

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