About Us - Medical Authorization Form

MEDICAL AUTHORIZATION

I,                                                                         , a resident of the State of Maryland, custodial parent or legal guardian of                                , whose date of birth is (“my child”), do hereby designate and appoint                                                 (“my Agent”) as my attorney-in-fact and agent to act on my behalf with respect to any and all medical needs of my child, including but not limited to the following:

a)  To consent to any X-ray examination, anesthetic, medical or surgical diagnostic procedure or treatment, and hospital care to be rendered to my child under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the jurisdiction where my child is then situate;

b)   To consent to any X-ray examination, anesthetic, dental or surgical diagnostic procedure or treatment, and hospital care to be rendered to my child by any dentist licensed to practice in the jurisdiction where my child is then situate;

c)   To request, receive, and review any pertinent medical or dental records;

d)   To employ and discharge health care providers, including but not limited to physicians, surgeons, and dentists, as may my Agent may deem necessary or appropriate;

e)   To summon paramedics or other emergency medical personnel and seek emergency treatment;

f)   To revoke, withdraw, modify, or otherwise change any consent granted hereunder;

g)   To exercise all rights of privacy in making decisions concerning medical treatment; and h)   To photocopy this Medical Authorization.

Anyone relying or acting upon this Medical Authorization at any time within one (1) year after the Effective Date set forth below shall be entitled to presume conclusively that it is in full force and effect unless I have given written notice to that person or entity that this power has been revoked. All photocopies of this Medical Authorization shall have the same force and effect as an original.

All questions pertaining to the validity, construction, and interpretation of this Medical Authorization shall be determined in accordance with Maryland law, and I intend that this Medical Authorization shall be honored in any jurisdiction (within or without the United States) where it may be presented.

This Medical Authorization shall not be affected by any disability of me and shall remain in effect for a period of one (1) year from the Effective Date set forth in the next paragraph.

IN WITNESS WHEREOF, I have executed this Medical Authorization on the                 201_ (the “Effective Date”).

WITNESS:

day of                    ,

STATE OF MARYLAND

COUNTY OF                                              

I HEREBY CERTIFY that on this           day of        , 201_ before me, a Notary Public in and for the state and

county aforesaid, personally appeared, known to me or satisfactorily proven to be the person who executed the foregoing instrument, who acknowledged that the same is his/her act and deed.

IN WITNESS WHEREOF, I have put my hand and notarial seal.