Authorization for Medical Care of a Minor Template (Simple)

Parent authorizes a caregiver (grandparent, coach, sitter) to get medical care for a child.

Use this free template Free account, so you can save and send it. Log in

Simple: a 1–2 page short form with just the core terms.

This template is not legal advice; consult a licensed attorney in your state. This template is not legal advice or medical advice; consult a licensed attorney in your state. Health privacy (HIPAA and state law), consent for minors, and telehealth rules vary; covered entities should have counsel review these forms.
E-Sign Auto is not a law firm and does not provide legal advice.

Find an attorney to review this → Family attorneys who offer a free consultation. Not an endorsement.

1. Parties2. Details 1/23. Details 2/2

Parties

Signing order: Parent / Guardian → Caregiver. Each signer is invited after the previous one signs.

1. Parent / GuardianFull name *Email (to send the signing link)

2. CaregiverFull name *Email (to send the signing link)

Signature, date and name fields are added for every signer automatically.

Details 1/2

Effective date *Child name and date of birth *Allergies, conditions and medicationsInsurance carrier and member ID *Start date *End date *

Details 2/2

Parent phone *Governing state *County where notarized (if notarized)

Use this free template (sign up)

Signature, initials (every page) and date fields are placed for each party. A witness/notary block is included. You can review and adjust them before sending.

Live preview

What the sections mean (plain English)

STATE RULES: What the property or item may and may not be used for.

How to use this Authorization for Medical Care of a Minor template

Answer the guided questions. Your name and company fill in automatically from your profile.
Pick the governing state and complete the [STATE-SPECIFIC] blanks. Switch optional clauses on or off.
Check the live preview, then create the document. Signature, initial and date fields are placed for each party.
Review the fields and send. Each party signs in order, and everyone gets the signed PDF.

Frequently asked questions

Is this Authorization for Medical Care of a Minor template free?

Yes. You can fill it in, download it and send it for electronic signature with a free E-Sign Auto account.

Is an electronically signed Authorization for Medical Care of a Minor legally binding?

In the U.S., the federal ESIGN Act and state UETA laws generally give e-signatures the same effect as handwritten ones, but this type of document often also needs witnesses or a notary, and some states require wet-ink signatures. Check your state's rules.

Does this template work in my state?

It is a generic, state-neutral starting point. Pick your governing state and complete every blank marked [STATE-SPECIFIC]. This template is not legal advice; consult a licensed attorney in your state.

Who signs, and in what order?

Parent / Guardian, then Caregiver. Each signer gets a secure link in that order, with signature, initial and date fields already placed.