When we went out of town & left our children w/ my parents, I left w/ them a signed & notarized statement giving my parents our permission to seek, authorize, and obtain emergency medical treatment for both children. (I had a form for each child). Both my husband and myself signed the forms in the presence of a notary. The form also included the names of our children, their social security numbers, our full names, our home address and telephone number, my husband's place of employment, the name of our insurance w/ the corresponding group number and telephone number, and copies of our insurance card.
It looked something like this --
MEDICAL RELEASE AUTHORIZATION STATEMENT
for
[child's name]
by his parents
[parents' names]
We, [parents' names], as the natural parents and legal guardians of [child's name] (ssn: [ssn#]), do hereby authorize [grandparents' names], as the natural and maternal grandparents of [child's name], to seek, authorize, and obtain medical care for [child's name] at that time such medical care is needed.
[child's name] currently has health insurance coverage as [husband's name]'s dependent with [insurance company] ([insurance 1-800 #]). The group code number is [group #], and the subscriber identification number is [subscriber ID #]. ([husband's name] is currently employed with the [husband's place of emplyment].)
[child's name]'s current medical records are with [name of doctor's office] ([telephone # of doctor's office]). [child's name]'s date of birth is [child's date of birth], and his home address and telephone number are as follows: [home address and telephone number].
Attached are copies of the insurance card under which [child's name] is currently covered and of [child's name]'s social security card.
Signed and Notarized
_________________________ _________________________
[parents' names, home address, and telephone numbers - home, work, & cell]
-notary seal-
