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1. Parties: Identifies current guardian, temporary guardian, and minor
2. Background: Explains circumstances necessitating temporary guardianship
3. Definitions: Key terms used in the document
4. Grant of Authority: Specific medical decisions temporary guardian is authorized to make
5. Duration: Time period for which temporary guardianship is valid
6. HIPAA Authorization: Authorization for release of medical information to temporary guardian
1. Insurance Information: Details of medical insurance coverage when temporary guardian needs to handle insurance matters
2. Travel Authorization: Permission for temporary guardian to travel with minor when medical treatment might require travel
3. Religious Restrictions: Specific religious limitations on medical treatment when religious beliefs affect medical decisions
1. Schedule A - Medical History: Child's medical history, allergies, and current medications
2. Schedule B - Emergency Contacts: List of emergency contacts including primary guardian and medical providers
3. Schedule C - Authorized Medical Procedures: Specific procedures temporary guardian is authorized to approve
4. Appendix 1 - State-Specific Requirements: Additional forms or requirements specific to the state
Primary Guardian
Minor
Medical Care
Emergency Medical Care
Healthcare Provider
Medical Records
Protected Health Information
HIPAA
Consent
Medical Treatment
Authorization Period
Effective Date
Termination Date
Revocation
Emergency Contact
Medical Facility
Insurance Provider
Routine Medical Care
Non-Emergency Medical Care
Duration and Termination
Scope of Medical Care
Emergency Treatment Authorization
HIPAA Compliance
Release of Information
Insurance Authorization
Indemnification
Revocation Rights
Limitations of Authority
Emergency Contact Procedures
Medical History Access
Religious or Cultural Restrictions
Travel Authorization
Liability Waiver
Notice Requirements
Governing Law
Severability
Healthcare Provider Rights
Successor Guardian Provisions
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