WITNESS THIS AGREEMENT AND AUTHORIZATION by and between ___________________________, hereinafter referred to as “Management,” and ___________________________, hereinafter referred to as “Parent.”
Management is hereby authorized to obtain any and all medical treatment Management deems reasonable necessary for my minor child and/or children.
Parent or guardian agrees to bear any cost connected therewith and shall pay promptly upon billing by the health care provider. Management shall incur no financial liability for medical treatment obtained pursuant to this authorization.
Name(s) of Child(ren) Social Security No.
____________________________________ ______________________________
____________________________________ ______________________________
____________________________________ ______________________________
Health Insurance Carrier: ________________________________________________
Plan or Identification No. ________________________________________________
Primary Healthcare Provider ________________________________________________
___________________________________________
Signature of Parent or Guardian
STATE OF TEXAS
COUNTY OF ___________________________
This instrument was acknowledged before me on _____________________ (date) by _____________________________________________________ (name or names of person or persons acknowledging).
______________________________
Notary Public
______________________________
Printed Name
My Commission expires: ______________________________________________
