Policy Number:      FRDK 095

Original Date:        April 2003

Revised Date:

Page 1 of 3

 

PRACTICE PROCEDURES

 

SUBJECT:     USING THE MEDICAL POWER OF ATTORNEY FORM

 

OVERVIEW:                   Maryland Law prohibits medical facilities from providing any type of

                                          medical care beyond life-saving treatment to ill or injured children

                                          without parental consent. This Medical Power of Attorney enables

                                          relatives or friends to consent to your child’s emergency medical care

                                          when you are away or when you are not able to attend a visit with your

                                          child.

 

PROCEDURE:

 

  1. Medical Power of Attorney forms shall be available in the office for patients to complete.

 

  1. As stated above this form allows family members or friends of the parents to make medical decisions for an injured child in an emergency situation.

 

  1. Obtain form FRDK 095.A and ask the parent or legal guardian to complete all sections.

 

  1. One form must be completed for each child. DO NOT insert multiple children’s names on the same form.

 

  1. A employed staff member must sign as the witness at the bottom of the form for it to be valid.

 

  1. Retain a copy of this completed form in the patients medical record to reflect upon in case of an emergency situation.

 

 

 

 

 

 

 

 

 

 

 

Medical Power of Attorney

 

Maryland Law prohibits medical facilities from providing any type of medical care beyond life-saving treatment to ill or injured children without parental consent. This Medical Power of Attorney enables relatives or friends to consent to your child’s emergency medical care when you are away or when you are not able to attend a visit with your child.

 

From:         ____________________________________________________________________

                                                            (Full Name(s) of Parent(s) or Guardian)

 

To:             ____________________________________________________________________

                                                            (Name(s) of Adult(s) responsible for child)

 

       We (I)      _______________________________________________________________________

                                                            (Full Name(s) of Parent(s) or Guardian)

 

of   _________________________________________________________________________________

                                                                         (Residential Address In Full)

 

Do hereby appoint  __________________________________________________________________

                                                                         (Name(s) of Adult(s) responsible for child)

our true and lawful attorney in fact, with full power to loco parentis, to decide upon and consent to the rendering of any medical diagnosis and treatment, including surgery, which (he or she) deems in the best interest of the health and welfare of our child.

 

____________________________________________________________________________________

(Name of the child)

 

This Power of Attorney shall be effective during such period of time as we, or either of us, may for any reason not be available to give our consent to any medical diagnosis or treatment, including surgery for our child.

 

This Power Of Attorney shall not be affected by the disability of either or both of us, but shall continue in full force and effect during any such disability.

 

Executed this _____  day of  ____________ , 20 ____.

 

Witness:

 

________________________________________                  ___________________________________

                                                                                                                           (Signature of Parent or Guardian)

 

________________________________________                  ___________________________________

                   (Name and address of witness)                                                     (Signature of Parent or Guardian)

 

________________________________________                  ___________________________________

 

 

________________________________________                  ___________________________________

                   (Name and address of witness)                                                     

FRDK 095.A

 

General Information About Child

 

Existing Medical problems of Child: ___________________________________________________

 

                                                             ___________________________________________________

 

Child’s allergies, if any: ______________________________________________________________

 

Primary Physician:   _________________________________________________________________

 

Choice of Specialists: _________________________________________________________________

 

Current medication child is taking: ____________________________________________________

 

                                                           ____________________________________________________

 

Insurance Company/Policy number: ___________________________________________________

 

Other information you would like us to know about your child: __________________________

 

_____________________________________________________________________________________

 

_____________________________________________________________________________________

 

_____________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FRDK 095.A