Form DOC20-279 "Consent to Medical Treatment and Waiver of Liability (Visitors)" - Washington

What Is Form DOC20-279?

This is a legal form that was released by the Washington State Department of Corrections - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 24, 2016;
  • The latest edition provided by the Washington State Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOC20-279 by clicking the link below or browse more documents and templates provided by the Washington State Department of Corrections.

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Download Form DOC20-279 "Consent to Medical Treatment and Waiver of Liability (Visitors)" - Washington

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CONSENT TO MEDICAL TREATMENT AND
WAIVER OF LIABILITY (VISITORS)
I,
, being an authorized visitor under
(Name)
the Extended Family Visitor Program or other authorized program of the Department of Corrections, being eighteen (18)
years of age or older, do hereby give my consent and authorize a Department of Corrections’ health care provider to
provide emergency medical treatment (first aid) or other non-definitive primary care as may be necessary to prevent
pain, suffering, or prevent imminent threat to my life, limb or the following minor(s) as a result of an emergency situation.
I have the authority to make medical decisions for the minor(s) listed below,
Minor(s)Name
Date of Birth
I hereby do waive, relinquish, and release any and all claims, demands, or causes of action which may arise against the
state of Washington, Department of Corrections, the attending health care provider and all officers and employees of the
Department of Corrections accruing directly as a result of each treatment, or as an indirect result of the administration of
such medical treatment which, in the discretion of the health care provider, was reasonably necessary or advisable for
dealing with an emergent health care problem.
I do hereby further state that I have read the foregoing consent to treatment and waiver of liability and understand the
contents thereof, and that such consent to treatment and waiver of liability are given of my own free act and deed and not
under any undue influence, threat, or coercion.
Consenting Visitor Signature
Date
Subscribed and sworn to before me this
day of
20
.
STATE OF
)
)
ss.
County of
)
(Signature)
NOTARY PUBLIC
Title
SEAL
Printed Name
My Commission Expires
Distribution: ORIGINAL-Visiting Department
COPY-Offender Central File
DOC 20-279 (Rev. 08/24/16)
DOC 590.100
CONSENT TO MEDICAL TREATMENT AND
WAIVER OF LIABILITY (VISITORS)
I,
, being an authorized visitor under
(Name)
the Extended Family Visitor Program or other authorized program of the Department of Corrections, being eighteen (18)
years of age or older, do hereby give my consent and authorize a Department of Corrections’ health care provider to
provide emergency medical treatment (first aid) or other non-definitive primary care as may be necessary to prevent
pain, suffering, or prevent imminent threat to my life, limb or the following minor(s) as a result of an emergency situation.
I have the authority to make medical decisions for the minor(s) listed below,
Minor(s)Name
Date of Birth
I hereby do waive, relinquish, and release any and all claims, demands, or causes of action which may arise against the
state of Washington, Department of Corrections, the attending health care provider and all officers and employees of the
Department of Corrections accruing directly as a result of each treatment, or as an indirect result of the administration of
such medical treatment which, in the discretion of the health care provider, was reasonably necessary or advisable for
dealing with an emergent health care problem.
I do hereby further state that I have read the foregoing consent to treatment and waiver of liability and understand the
contents thereof, and that such consent to treatment and waiver of liability are given of my own free act and deed and not
under any undue influence, threat, or coercion.
Consenting Visitor Signature
Date
Subscribed and sworn to before me this
day of
20
.
STATE OF
)
)
ss.
County of
)
(Signature)
NOTARY PUBLIC
Title
SEAL
Printed Name
My Commission Expires
Distribution: ORIGINAL-Visiting Department
COPY-Offender Central File
DOC 20-279 (Rev. 08/24/16)
DOC 590.100