Hospitals, Doctors, Schools, Churches and other entities are not required to honor the Medical Authorization Form. Although a Power of Attorney may be revoked at any time by the person granting the power, fully revoking it may sometimes be difficult to do. A hospital, medical provider, school, church or other entity that relies upon a Power of Attorney that you have executed must have actual notification that the Power of Attorney has been revoked, or it may continue to honor it. A Power of Attorney does not grant any powers to act after the death of the person granting it, nor after the date of expiration shown on the power. It is not a substitute for probate, nor guardianship. This Medical Authorization Power of Attorney is not a relingquishment of the rights of a parent to the child, and takes no rights away from the parent.

Generally we can prepare a Medical Authorization Power of Attorney for you from information you furnish in the form below.

We Prepare Two Original Medical Authorization Powers of Attorney for Execution We Also Provide Complete instructions for the execution and use of the Medical Authorization Power of Attorney. Our Charge for the Service is $75.00

You May Complete The Following Form to Provide All of the Information We Need To Prepare Your Medical Authorization Power of Attorney.

If you have specific questions concerning your Power of Attorney, please E-Mail your questions. You should get a response by the next business day.

If more information is necessary we will send you an E-Mail requesting more specific information.

In Filling Out This Information Form, the parties will be referred to as Custodian and Attorney.

The Custodian is the person who has legal custody of the child. Generally these would be the parents, but in the event of divorce, the custodian is the parent having legal custody by court order.

Both parents should sign the form unless one parent has been given legal custody by court order.

This must be signed before a Notary Public.

The Attorney is the person who is granted the powers to act for an in behalf of the Custodian.

This Attorney does not need to sign the instrument.

Information About The Child

Full Name of Child: -

Social Security Number -

Street Address of Child -

City, State & Zip Code -

Child's Phone Number -

County of Child's Residence -

Date of Birth of Child -

Birth Place of Child -

Gender of the Child - Male Female

Information About Custodian No. 1

Full Name of Custodian: -

Relationship to Child ( Mother, Father, etc. ): -

Street Address of Custodian -

City, State & Zip Code -

Custodian's Phone Number -

Custodian's E-Mail -

County of Custodian's Residence -

Gender of the Custodian - Male Female

Information About Custodian No. 2 If There is Only One Legal Custodian Skip This

Full Name of Custodian: -

Relationship to Child ( Mother, Father, etc. ): -

Street Address of Custodian -

City, State & Zip Code -

Custodian's Phone Number -

Custodian's E-Mail -

County of Custodian's Residence -

Gender of the Custodian - Male Female

Information About Attorney No. 1 ( Person Receiving Power of Attorney )

Full Name of Attorney: -

Relationship to Child ( Grandmother, Grandfather, Friend, etc. ): -

Street Address of Attorney -

City, State & Zip Code -

Custodian's Phone Number -

Custodian's E-Mail -

County of Attorney's Residence -

Gender of the Attorney - Male Female

Information About Attorney No. 2 ( Person Receiving Power of Attorney ) If There is Only One Person Receiving Power Skip This


Full Name of Attorney: -

Relationship to Child ( Grandmother, Grandfather, Friend, etc. ): -

Street Address of Attorney -

City, State & Zip Code -

Custodian's Phone Number -

Custodian's E-Mail -

County of Attorney's Residence -

Gender of the Attorney - Male Female

This Power of Attorney Expires ( Date of Expiration )
[ If No Expiration Date - Type None ]




Powers To Be Granted - ( What Attorney Can Do for Child )
Consent to Medical Treatment - Yes No

Consent to Dental Treatment - Yes No

Consent to School Enrolment - Yes No

Consent to School Trips & Outings - Yes No

Consent to Church Trips & Outings - Yes No

Consent to Picking Up From School & Other Functions - Yes No

Power to File Claims For Insurance Benefits - Yes No

Power to Obtain Medical Information - Yes No

Power to Obtain School Information - Yes No




Please add any comments you have below:

---

Send Completed Forms To: Full Name - First, Middle, Last: Mailing address: Street address or P.O. Box: City: State or Province: Zip or Postal Code: County: Telephone: Fax: E-mail address:

CONFIRMATION AND PAYMENT INFORMATION

Payment May be by one of the following credit cards.

---

Charge to My Credit Card - - Yes - No

Visa
Mastercard

Card Number - - -

Expiration Date MM YYYY

E-mail this form by pressing the SUBMIT button below -

OR

Complete and Sign this form and fax it to (405) 275-3627

OR

Complete and Sign this form and mail it to:

OkLegal Forms - Internet Services
McKIMMEY LAW OFFICE, P.C.
24 E. Highland
Shawnee, Oklahoma 74801

With Your Check for $75.00, or your Credit Card Number.

OR

If you wish, you may e-mail the form to us and call us with your credit card number at 405-275-3564.

Credit Card Orders Usually Sent First Class Mail to Address of Plaintiff on the same day received. Orders accompanied by check are sent upon notice by bank that check has cleared.

By returning this form by e-mail, by fax or by mail, I acknowledge and agree to the following:

I hereby certify as follows:

• That I am a resident of the State of Oklahoma, and have been for more than six months prior to this date.
  
  
• That I am a bona fide resident of the County shown to be my address herein.
  
  
• That the Custodian of the Power of Attorney is 21 years of age or over.
  
  
• That the Custodian of the Power of Attorney is mentally competent to execute the Power of Attorney.
  
  
• That McKimmey Law Office, P.C. has not provided me any legal or tax services or advice concerning this matter.
  
  

• Signature (if sending by fax or by mail)
  
  
  __________________________________

  Type your name: -

  
  

  Please tell us how you found us on the Internet, i.e., what search terms, what search engines, links, etc.

oklegalforms@yahoo.com

Other Services Now Offered [ ] [ Amortization Schedule ] [ Certificate of Incorporation ] [ Deed Preparation ] [ Divorce - Waiver Set ] [ Joint Tenancy Termination ] [ Medical Authorization for Care of Minor ] [ Change of Name ] [ Power of Attorney ] [ Pre-Nuptial Agreement ] [ Promissory Note ] [ Release of Mortgage ] [ Vacate Divorce Decree ]

- 2001 - McKimmey Law Office, P.C.

McKimmey Law Office, P.C. Wills - Probate - Real Estate - Civil Rights Pre-Nuptial Agreements - Common Law Marriage Schedule of Fees and Services

Amortization Schedule

Time Charge

PortFolio

---

- The Imaginary Company

Web Page by The Imaginary Company



11/9/06