Parental Designation Form

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Parent Designation to Permit Another Person to Consent for Health Care
1. I/we hereby state that I am/we are parent(s) of the child(ren) named below and there are no court orders now in effect that would prohibit the exercise of the power that I/we now seek to authorize.
2.This designation shall permit

,(designee) to give consent for health care services for the following individuals:
Name
First Last
Date of Birth
MM slash DD slash YYYY
Name
First Last
Date of Birth
MM slash DD slash YYYY
Name
First Last
Date of Birth
MM slash DD slash YYYY
Name
First Last
Date of Birth
MM slash DD slash YYYY
3.This designation shall be valid from
until and including
4. As to the above named child(ren), the designee is authorized to:
Consent to immunizations
Consent to general health care, including examination and treatment
Consent to dental care
Consent to developmental screening
Consentto mental health examination and or treatment
The designee's authority is limited as follows:
The word "parent" is specifically used in the statute, and therefore it is questionable whether a non-parent legal guardian has the power to delegate authority to a designee under the law. General obligations Law 501551. Parents may appoint a designee for minor children, as well as incapaciated children. If a court has ordered that both parents must agree on health care decisions, both parents must sign this designation.
5. Revocation: I understand that this designation shall be revoked by any of the following:
- a. A parent may revoke a designation by notifying the healthcare provider either verbally or in writing, or by any other act evidencing a specific intent to revoke the designation, or by executing a subsequent designation.
- b. If both parents have signed this designation, and either of the parents revokes it, the authority of the designee is revoked.
- c. A designee must notify all appropriate health care providers of anyh revocation of his or her authority.
- d. If the parent who signed a designation becomes incapacitated or dies, the designation is revoked.
Parent's signature
Date
MM slash DD slash YYYY
Parent's Name
Telephone Number
Patient's address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
On this day before me the undersigned, a notary public in and for said state, personally appeared
MM slash DD slash YYYY
Personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual or the person upon behalf of which the individual acted, execute the instrument.
Notary Public
Parent's Signature
Date
MM slash DD slash YYYY
Parent's Name
Telephone Number
Parent's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parental Designation Form

Parent Designation to Permit Another Person to Consent for Health Care