"Caretaker Relative's Medical Authorization Affidavit" - Montana

Caretaker Relative's Medical Authorization Affidavit is a legal document that was released by the Montana Department of Public Health and Human Services - a government authority operating within Montana.

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Download "Caretaker Relative's Medical Authorization Affidavit" - Montana

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CARETAKER RELATIVE'S MEDICAL AUTHORIZATION AFFIDAVIT
Use of this affidavit is authorized by 40-6-502, MCA.
1. INSTRUCTIONS: The completion and signing of the affidavit before a notary public are sufficient to authorize medical care for
the named child. Please print clearly.
The child named below lives in my home, and I am 18 years of age or older.
a. Name of child:
b. Child’s date of birth:
c. My name (caretaker relative):
d. My home address:
e. My relationship to the child (the caretaker relative must be an individual related by blood, marriage, or adoption by another
individual to the child whose care is undertaken by the caretaker relative, but who is not a parent, foster parent, stepparent, or
legal guardian of the child):
2. I hereby certify that this affidavit is not being used for an unlawful purpose
.
3. My date and year of birth: ____________________________________
4. Check the following if true (all must be checked for this affidavit to apply):
A parent of the child identified in paragraph 1a of this affidavit has left the child with me and has expressed no definite time
period when the parent will return for the child.
The child is now residing with me on a full-time basis.
I am unable to locate or contact the parent of the child at this time to notify that parent of my intended authorization, or the
parent refuses to regain custody of the child even though I have asked in writing that the parent do so.
No adequate provision, such as appointment of a guardian ad litem or execution of a power of attorney, has been made for
medical care for the child.
5. WARNING: DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ABOVE ARE INCORRECT OR YOU
WILL BE COMMITTING A CRIME PUNISHABLE BY A FINE, IMPRISONMENT, OR BOTH.
6. I declare under penalty of false swearing under the laws of Montana that the foregoing is true and correct.
______________________________________________ Signed this _______ day of __________________20____
(Signature of caretaker relative)
personally appeared before me and whose identity I proved on the basis of satisfactory evidence to be
Print Name from Identification
the signer of the above instrument.
Subscribed and sworn to before me this
day of
20____
Notary’s Signature
SEAL
Printed Name:
Notary Public in and for the State of
Residing at
My commission expires
7. NOTICES:
a. Completion of this affidavit does not affect the rights of the child's parent or legal guardian regarding the care, custody, and
control of the child and does not mean that the caretaker relative has legal custody of the child.
b. A health care provider who relies on this affidavit has no obligation to make any further inquiry or investigation.
c. This affidavit is not valid for more than 6 months after the date on which it is signed by the caretaker relative.
8. ADDITIONAL INFORMATION:
a. TO CARETAKER RELATIVES: If the child stops living with you, you shall notify anyone to whom you have given this
affidavit, as well as anyone who has received the affidavit from someone else.
b. TO PUBLIC AND PRIVATE HEALTH CARE PROVIDERS AND PUBLIC AND PRIVATE SCHOOL OFFICIALS:
A public or private health care provider or a public or private school official who acts in good faith reliance upon a caretaker
relative medical authorization affidavit to provide medical care, without actual knowledge of facts contrary to those indicated in
the affidavit, is not subject to criminal prosecution or civil liability to any person, or subject to any professional disciplinary
action, for reliance on the affidavit if the form is completed in compliance with 40-6-502, MCA.
CARETAKER RELATIVE'S MEDICAL AUTHORIZATION AFFIDAVIT
Use of this affidavit is authorized by 40-6-502, MCA.
1. INSTRUCTIONS: The completion and signing of the affidavit before a notary public are sufficient to authorize medical care for
the named child. Please print clearly.
The child named below lives in my home, and I am 18 years of age or older.
a. Name of child:
b. Child’s date of birth:
c. My name (caretaker relative):
d. My home address:
e. My relationship to the child (the caretaker relative must be an individual related by blood, marriage, or adoption by another
individual to the child whose care is undertaken by the caretaker relative, but who is not a parent, foster parent, stepparent, or
legal guardian of the child):
2. I hereby certify that this affidavit is not being used for an unlawful purpose
.
3. My date and year of birth: ____________________________________
4. Check the following if true (all must be checked for this affidavit to apply):
A parent of the child identified in paragraph 1a of this affidavit has left the child with me and has expressed no definite time
period when the parent will return for the child.
The child is now residing with me on a full-time basis.
I am unable to locate or contact the parent of the child at this time to notify that parent of my intended authorization, or the
parent refuses to regain custody of the child even though I have asked in writing that the parent do so.
No adequate provision, such as appointment of a guardian ad litem or execution of a power of attorney, has been made for
medical care for the child.
5. WARNING: DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ABOVE ARE INCORRECT OR YOU
WILL BE COMMITTING A CRIME PUNISHABLE BY A FINE, IMPRISONMENT, OR BOTH.
6. I declare under penalty of false swearing under the laws of Montana that the foregoing is true and correct.
______________________________________________ Signed this _______ day of __________________20____
(Signature of caretaker relative)
personally appeared before me and whose identity I proved on the basis of satisfactory evidence to be
Print Name from Identification
the signer of the above instrument.
Subscribed and sworn to before me this
day of
20____
Notary’s Signature
SEAL
Printed Name:
Notary Public in and for the State of
Residing at
My commission expires
7. NOTICES:
a. Completion of this affidavit does not affect the rights of the child's parent or legal guardian regarding the care, custody, and
control of the child and does not mean that the caretaker relative has legal custody of the child.
b. A health care provider who relies on this affidavit has no obligation to make any further inquiry or investigation.
c. This affidavit is not valid for more than 6 months after the date on which it is signed by the caretaker relative.
8. ADDITIONAL INFORMATION:
a. TO CARETAKER RELATIVES: If the child stops living with you, you shall notify anyone to whom you have given this
affidavit, as well as anyone who has received the affidavit from someone else.
b. TO PUBLIC AND PRIVATE HEALTH CARE PROVIDERS AND PUBLIC AND PRIVATE SCHOOL OFFICIALS:
A public or private health care provider or a public or private school official who acts in good faith reliance upon a caretaker
relative medical authorization affidavit to provide medical care, without actual knowledge of facts contrary to those indicated in
the affidavit, is not subject to criminal prosecution or civil liability to any person, or subject to any professional disciplinary
action, for reliance on the affidavit if the form is completed in compliance with 40-6-502, MCA.