Caregivers Authorization Affidavit PDF Details

The Caregivers Authorization Affidavit is a legal document that healthcare providers use to authorize individuals to provide care for patients. The affidavit allows caregivers to make medical decisions on behalf of the patient, as well as access the patient's medical records. The affidavit must be signed by both the caregiver and the patient, and must be notarized. Healthcare providers often require a copy of the affidavit before authorizing a caregiver to provide care for a patient. The Caregivers Authorization Affidavit can be download from our website at www.caregiversauthorizationaffidavit.com . Thank you for reading! We hope this blog post was informative and helpful.

The listing includes information about the caregivers authorization affidavit. It's definitely worth making the effort to study this prior to starting filling out your form.

QuestionAnswer
Form NameCaregivers Authorization Affidavit
Form Length3 pages
Fillable?Yes
Fillable fields6
Avg. time to fill out2 min 1 sec
Other namescaregiver affidavit form california, california courts caregivers affidavit, caregiver affidavit, caregivers affidavit ca

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Caregiver's Authorization Affidavit

Use of this affidavit is authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the California Family Code.

Instructions: Completion of items 1 - 4 and the signing of the affidavit is sufficient to authorize enrollment of a minor in school and authorize school- related medical care. Completion of items 5-8 is additionally required to authorize any other medical care. Print clearly.

The minor named below lives in my home and I am 18 years of age or older.

1.Name of minor: ______________________________.

2.Minor's birth date: _____________________.

3.My name (adult giving authorization): _______________________________.

4.My home address (street, apartment number, city, state, zip code):

______________________________________________

______________________________________________

______________________________________________

5.I am a grandparent, aunt, uncle, or other qualified relative of the minor (see page 2 of this form for a definition of "qualified relative").

6.Check one or both (for example, if one parent was advised and the other cannot be located):

I have advised the parent(s) or other person(s) having legal custody of the minor of my intent to authorize medical care, and have received no objection.

I am unable to contact the parent(s) or other person(s) having legal custody of the minor at this time, to notify them of my intended authorization.

7.My date of birth: ______________________.

8.My California's driver's license or identification card number: ____________.

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.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Dated: _____________________ Signed: ________________________

California Courts Self-Help Center www.courtinfo.ca.gov/selfhelp/

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Notices:

1.This declaration does not affect the rights of the minor's parents or legal guardian regarding the care, custody, and control of the minor, and does not mean that the caregiver has legal custody of the minor.

2.A person who relies on this affidavit has no obligation to make any further inquiry or investigation.

3.This affidavit is not valid for more than one year after the date on which it is executed.

Additional Information:

TO CAREGIVERS:

1."Qualified relative," for purposes of item 5, means a spouse, parent, stepparent, brother, sister, stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or any person denoted by the prefix "grand" or "great," or the spouse of any of the persons specified in this definition, even after the marriage has been terminated by death or dissolution.

2.The law may require you, if you are not a relative or a currently licensed foster parent, to obtain a foster home license in order to care for a minor. If you have any questions, please contact your local department of social services.

3.If the minor stops living with you, you are required to notify any school, health care provider, or health care service plan to which you have given this affidavit.

4.If you do not have the information requested in item 8 (California driver's license or I.D.), provide another form of identification such as your social security number or Medi-Cal number.

TO SCHOOL OFFICIALS:

1.Section 48204 of the Education Code provides that this affidavit constitutes a sufficient basis for a determination of residency of the minor, without the requirement of a guardianship or other custody order, unless the school district determines from actual facts that the minor is not living with the caregiver.

2.The school district may require additional reasonable evidence that the caregiver lives at the address provided in item 4.

California Courts Self-Help Center

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www.courtinfo.ca.gov/selfhelp/

 

TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:

1.No person who acts in good faith reliance upon a caregiver's authorization affidavit to provide medical or dental care, without actual knowledge of facts contrary to those stated on the affidavit, is subject to criminal liability or to civil liability to any person, or is subject to professional disciplinary action, for such reliance if the applicable portions of the form are completed.

2.This affidavit does not confer dependency for health care coverage purposes.

California Courts Self-Help Center

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www.courtinfo.ca.gov/selfhelp/

 

How to Edit Caregivers Authorization Affidavit Online for Free

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In order to fill in the form, type in the details the program will require you to for each of the appropriate sections:

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Feel free to type in your information in the field Use of this affidavit is, and (cid:70) I have advised the.

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Jot down the significant particulars in California Courts Self-Help Center, and Page 1 of 3 segment.

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Step 4: To prevent yourself from any kind of difficulties as time goes on, you should create up to several copies of your document.

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