Consent Forms – Authorization Forms

Medical Consent for the Treatment of a Minor

authorizationforms — Tue, 14 Nov 2017 00:22:55 +0000

The medical consent for the treatment of a minor is a simple but important document that grants authority to a designated adult to care for the child of the signatory in the case of a medical emergency. The authority is temporary, the start and end date will be provided within the document. As it is not always possible or practical to contact the parents or legal guardians of a child when there is a medical emergency, this document allows the designated adult to provide minor first aid and seek emergency treatment as they deem necessary.

How to Write

Step 1 – Download in Adobe PDF.

Minor Child Medical Authorization Form

Step 2 – Once the form has been downloaded, provide the minor’s full name, home address, date of birth, and gender.

Step 3 – Information for medical treatment must be supplied to the designated adult. This will include the child’s physician, the physician’s location of practice, and the physician’s phone number. The insurance plan name and policy number must be supplied as well. If the child has allergies to medication, they should be specified. All conditions for which the child is receiving treatment and any other applicable medical info must be provided in the final two fields.

Step 4 – The designated adult’s name can be entered in the paragraph field. Provide the date for the end of authorization, and the day the document is being signed. Sign the form, and print your name. A witness must be present and do the same.

FBI Background Check Authorization – Form I-783 and FD-258

authorizationforms — Sun, 30 Jul 2017 12:48:52 +0000

The FBI background check form gives the Federal Bureau of Investigations the authority to conduct a thorough review of your criminal history. This is common when applying for federal employment or for State recognized legal profession such as a medical physician or attorney. There are 2 ways to submit this form: through a LiveScan Location which processes the check immediately or through the standard mail.

Fees ($38 total) – $20 for fingerprinting and $18 for the background check.

How Long Does it Take? Between 4-6 business days.

Background Check Forms

FBI Background Authorization (Form I-783) – Granting release of your background information to the FBI.

Fingerprint Sheet (Form FD-258) – Print this form TWICE if you will be mailing the application.

*Credit Card Authorization – *Required only if payment is to be made by credit card. Personal and business checks are not accepted for payment.

How to Get an FBI Background Check

Step 1 – Download and print Form I-783 and FD-258 (print 2 copies).

Step 2 – Get your fingerprints taken. This will cost $20. If you live near a metropolitan area you may be able to get a LiveScan (View LiveScan Locations) which will send your fingerprints instantly to the FBI. Otherwise you will need to get your fingerprints completed at a Standard Fingerprint Location with at least 2 copies of Form FD-258.

Step 3 – Send the forms. If you did not use a LiveScan Location then you will need to send your 3 forms (1 Form I-783 and 2 Form FD-258), the *fee of $18 to:

FBI CJIS Division – Summary Request 1000 Custer Hollow Road Clarksburg, West Virginia 26306

*The fee is cannot be paid by personal or business check. A credit card may be provided by attaching the Credit Card Authorization Form or by enclosing a Certified Check or Money Order made to “Treasury of the United States“.

Waiting Period – The wait time is usually 4-6 business days. The background information will arrive in 1st Class USPS Mail.

How to Fill-in Form I-783

Step 1 – Download in Adobe PDF.

FBI Background Check Authorization Form – I-783

Step 2 – Begin by submitting the following applicant information in the first section of the form:

Full name
DOB
POB
U.S. citizen or legal permanent resident
Country of citizenship
Country of residence
Prisoner number (if applicable)
Last four digits of SSN
Height
Weight

Step 3 – Check the appropriate box that corresponds with the applicant’s hair color. Do the same for eye color.

Step 4 – Provide your home address and contact information here.

Step 5 – Supply the address to which the results should be sent. If the phone number of the contact person is different that the one listed before, enter it where applicable.

Step 6 – Check the box to indicate which payment method you’ll be using. Indicate your reason for the request as well where applicable. The date can be supplied followed by the applicant’s signature (once printed).

Minor Child Travel Consent Form

authorizationforms — Fri, 28 Jul 2017 00:10:49 +0000

The child consent form is used to provide a parent’s consent allowing their child to travel with another adult. As stated on the first page of this form, an immigration officer, airline, border guard or similar authority figure may ask for such a document to prove that the child isn’t being abducted by the adult accompanying them, and that the parent/guardian of the child is aware and consents to them travelling together. This document should completed and signed before a witnessed.

How to Write

Step 1 – Download in Minor Child Travel Consent Form.

Minor Child Travel Consent Form

Step 2 – Begin by filling in the full name, home address, DOB, and gender of the minor in question.

Step 3 – The child’s full name can again be entered here followed by the below info.

Full name of accompanying person
U.S. or foreign passport number of accompanying person
Date and place of issuance of this passport
Country being visited
Duration of trip
Child’s name
Name of person child will be residing with in foreign country

Step 4 – The number/street address and apartment number where the child will be staying must be specified along with the telephone, work, fax, and cell phone number of the residence.

Step 5 – Each parent/guardian must sign, give their printed name, and date the form.

Step 6 – The witness must also provide their full name, date, and location where form was completed. They too must supply their signature.

Drug and Alcohol Test Consent Form

authorizationforms — Fri, 28 Jul 2017 00:03:10 +0000

The drug and alcohol test consent form allows a 3rd party, usually an employer, to conduct a quick medical examination. The test will usually require the patient to supply a hair or urine sample. Afterwards the results of the test will be made known to the patient and, if positive, the employee or individual who’s been tested may face consequences if the company operates a drug-free work environment.

Random Drug Testing Consent (Adobe PDF, Microsoft Word) – For an employee that allows themselves to be drug tested at random.

How to Write

Step 1 – Download in Adobe PDF or Microsoft Word (.docx).

Drug and Alcohol Test Consent Form – Adobe PDF – MS Word

Step 2 – Enter your name at the top and that of the company. Ensure you read through the entirety of the form before providing any information however.

Step 3 – Before you print off the document and hand it back to your employer, HR officer, or whoever is performing the drug test, supply the following info:

Signature (once printed)
Date
Name
Street address
SSN
Home phone number
Email address
Zip code

Medicare Consent Form

authorizationforms — Thu, 27 Jul 2017 23:22:23 +0000

The Medicare consent form is used when a Medicare beneficiary wishes to authorize the release of their medical information from the Center for Medicare and Medicaid Services to an entity or individual. This can be health information or information as it pertains to the settlement received. It should be noted that if the beneficiary wishes to release their information to more than one entity or individual, they will need to fill out a separate form for each.

How to Write

Step 1 – Download in Adobe PDF.

Medicare Consent Form

Step 2 – Read over the information in the first couple of paragraphs before submitting your full name as shown on your Medicare card.

Step 3 – Check one of the boxes here to indicate who can receive the information. If “Other,” explain. After this, provide the following:

Name of entity
Contact for above entity
Address
Phone number

Step 4 – Specify the amount of time CMS may release the information by checking “One Year,” “Two Years,” or “Other.” Enter in the specific period of time if “Other” was selected.

Step 5 – The date signed, health insurance claim number, and date of injury/illness can all be provided before printing and signing the document.

Informed Consent Form for Research – Example

authorizationforms — Thu, 27 Jul 2017 23:11:58 +0000

The informed consent form for research is a document that ensures that a participant in a medical research project have been fully educated on the nature of the project and have been given ample opportunity to ask any questions they need to fill comfortable and informed. The form contains a list of statements which must be checked off before the document can be signed to indicate to participants full consent.

How to Write

Step 1 – Download in Adobe PDF (.pdf) or Microsoft Word (.docx).

Informed Consent Form – Adobe PDF – Microsoft Word (.docx)

Step 2 – Enter your name in the topmost field. Below this, in the field presented in the first statement, enter the date indicated on the information sheet. Check the first box if you have read and understood the information pertaining to the project. Check the second to show that you’ve had the opportunity to ask questions. Check the third to volunteer to participate.

Step 3 – Window 4 states that you can withdraw from the project at any point, for any reason, and you will not be penalized nor will you be asked to provide your reasoning. The fifth statement has to do with confidentiality and checking the corresponding box indicates that the confidentiality agreement has been clearly stated. If there are separate terms of consent for interviews and the like, those terms must be explained to you. If they have, check the box in window six (6).

Step 4 – The use of the data must be explained. If it has, check the applicable box. Other researchers will be privy to the data collected during the project and if they agree to the confidentiality terms, they will be given access. Check the box to approve this statement. You may select whether or not you would like your name used in the ninth window. The final window, simply pertains to the signing and dating of the form.

Step 5 – Print your name and the date where applicable before signing the document and given the researchers your consent to share the information as they deem necessary.

Body Piercing Consent Form – For Adults and Minors

authorizationforms — Thu, 27 Jul 2017 19:21:57 +0000

The body piercing consent form is for the benefit of the piercer and the individual getting the piercing. It enables the professional performing the piercing to ensure that their client doesn’t suffer from any affliction that may affect the outcome of the piercing, that they are not a minor, that they are requesting the piercing under their own free will, and that they are aware of all consequences that go along with piercing a body part. The client is able to ensure that the tools being used to conduct the piercing were sterile and that, before they sign the form, they have been provided with the aftercare instructions.

Minor (Child) Body Piercing Consent Form – Use in accordance with your State Laws.

How to Write

Step 1 – Download in Adobe PDF or Microsoft Word (.docx).

Body Piercing Consent Form – Adobe PDF – Microsoft Word (.docx)

Step 2 – Enter the name of the individual performing the piercing here. Be sure to read the intro paragraph.

Step 3 – Enter the body part being pierced in the first field. Make sure to obtain the amount of time it takes to heal then submit the info into the second field here. Read the remainder of the paragraph then submit the day’s date.

Step 4 – Your name, age, driver’s license number and address should be submitted here. Once the form has been printed, furnish it with your signature before handing the completed document to the piercer.

Dental Patient Consent Form

authorizationforms — Thu, 27 Jul 2017 18:26:07 +0000

The dental patient consent form is used for any type of oral surgery or treatment in order to hold the dentist harmless of any wrong-doing (unless there is evidence of malpractice). The surgery may be for any type of tooth repair/pulling/implant and whether the patient will be consciously sedated or put under anesthesia. The form should be signed by the patient before any medication or medical treatment is assigned for the operation.

Root Canal ONLY Consent Form (Adobe PDF, MS Word) – This is for the dentist to be able to provide services exclusively in relation to a needed root canal.

How to Write

Step 1 – Download in Adobe PDF (.pdf) or Microsoft Word (.docx).

Dental Patient Consent Form – Adobe PDF – MS Word

Step 2 – Enter the following information in the first portion of the form:

Patient name
Date of Birth
Name of dentist
Name of office
Tooth number

Check one of the available options to indicate the nature of the procedure.

Step 3 – The date and signature of each of the below individuals will be required before handing the form back to the reception of the dentist’s office.

Patient
Parent or legal guardian
Witness or interpreter
Dentist

Photo Consent Form

authorizationforms — Thu, 27 Jul 2017 17:50:35 +0000

The photo consent form is a simple document that grants permission to the photographer or to the individual for whom the photos are being taken to use the media as they wish. The form states that the permission can be revoked at any time by the photographed individual if they notify the photographer or issuer of the photographs in writing.

How to Write

Step 1 – Download in Adobe PDF (.pdf)

Photo Consent Form

Step 2 – In the first field, enter your name. The second and third field can be filled with the name of the individual requesting or taking the photographs.

Step 3 – Provide your personal information in this section of the form as follows:

Name
Address
Phone number
Email
Signature (once printed)
Date of signing

Describe the images you’re consenting to have used in the final field. Once printed, supply your signature where applicable.

Surgery Consent Form

authorizationforms — Thu, 27 Jul 2017 17:31:37 +0000

The surgery consent form is used to indicate that a patient receiving surgery or special procedures has been made aware of the nature of the operation, the risks involved, the required medication/anesthesia, and any other pertinent information that may effect their decision to consent. The patient must sign off taht they ahve had ample opportunity to field any questions they need answered and to address any concerns they might have going into the operation. The signature indicates that they believe they have enough information to classify their decision to have the operation as informed.

How to Write

Step 1 – Download in Adobe PDF.

Surgical Consent Form

Step 2 – The name of the patient and the name of the practitioner should be entered first. The surgery should be described and named by the practitioner in the paragraph field.

Step 3 – The patient may indicate whether or not the consent to receiving blood transfusions. If they do not consent, they must initial indicating that they understand that refusing blood transfusions may be dangerous and that they will be offered registration in the “Blood Alternative Program.”

Step 4 – The entire document should be read thoroughly by the patient and preferably by the patient’s attorney. The representative of the patient or the patient themselves will need to sign the document, and provide the date and time of their signature.

Step 5 – If the patient is unable to consent, their representative will be required to complete this section. The following must be supplied:

Name of patient’s authorized representative
Relationship to the patient
Signature/date/time
Reason consent can be provided
Name of witness
Witness signature

Step 6 – The practitioner must sing the form as well along with the date and time of their signature.