Caregiver Consent Form for Emergency Treatment
Today a head of household often has to delegate the care of a loved one to a caregiver. Most often this
involves ensuring care for a child. At other times, however, it may involve an adult who cannot act on his
or her own: an elderly parent, an ill spouse.
The caregiver could be one of many types of people:
A teen-aged child care provider for an evening.
An adult friend or relative for an extended period of time.
A professional caregiver, such as a nurse or home health aide.
Whatever the situation, it’s important to plan for the unexpected. If a medical emergency arises while the
head of the household is away, caregivers must be able to make decisions for those in their care. Medical
care personnel responding to the emergency must be assured that the caregiver has the authority to act for
Caregiver Consent Form
A Caregiver Consent Form, prepared in advance, assures that the caregiver will be able to make medical
decisions guided by health care professionals in your absence. You can create these forms without the
need for a lawyer. Place prepared consent form copies next to emergency phone numbers. Review the
Caregiver Consent form and emergency phone numbers frequently to keep them current.
Information to include:
Stated permission to have the caregiver arrange for emergency medical care.
Name of person receiving the care.
Name of the caregiver.
Name of head(s) of household and address.
Insurance carrier, with policy and group number.
Expiration date of consent.
Have a caregiver consent form for each child in the household. Remember to update the name of the
caregiver as it changes.
Multiple or customized forms:
The form on the next page can be photocopied as often as needed. Or, you may want to devise your own
form using it as a model.
It is not meant to take the place of sound legal advice. You may want to consult with your attorney to be
certain it is appropriate for your family’s particular needs. See next page for sample consent form.
Be sure to instruct your caregivers:
On the need for and use of the consent forms.
That the consent forms are in or by emergency phone numbers.
To give the Caregiver Consent Form to the Emergency Medical Service or to take it to the
emergency room so all necessary information for prompt and appropriate care will be
available in your absence.
To become familiar with the name and group number of you’re insurance carrier, a critical
concern to hospitals or other emergency centers.
Keep a photocopy of your Insurance ID Card with the form.