POA for Treatment of Minor Patient

Why Your Child Should Have a Power of Attorney for Treatment of Minor Patient on Record:

Why is it important to fill out a Minor POA form for the medical treatment of my child?

A Minor POA form appoints another trusted adult to act as a Parent Substitute to authorize medical care and treatment for your child. A properly completed Minor POA form enables Gundersen Health System to provide non-emergency medical care to your child when you are unable to bring your child to an appointment.

What is the purpose of the POA for Treatment of Minor Patient form?

Gundersen's POA for Treatment of Minor Patient Form is designed to accomplish one or more of the following as specified by the parent(s):

  • Appoint a Parent Substitute to authorize care and treatment for a minor patient.
  • Authorize the disclosure of the minor's protected health information to the Parent Substitute, which may be needed to make informed consent decisions.
  • If the parent(s) delegate full parental power, authorize Gundersen to release and discharge the patient from the hospital into the custody of the Parent Substitute.

Can more than one Parent Substitute be named?

The parent(s) can appoint more than one person to act as the Parent Substitute in their absence.

Can my child's stepparent give permission for medical care if a Minor POA form has not been signed?

NO. Even though stepparents are often actively involved in a child’s life, stepparents are not legal guardians. Without a Minor POA form designating a Parent Substitute, we need to contact a parent or legal guardian before providing non-emergency medical care.

If I have not signed a Minor POA form, can my child receive emergency care?

YES. A healthcare provider may legally treat a minor patient without parental consent in a medical emergency. The healthcare provider will use his or her judgment to determine if the child requires emergency care.

Where do I get a Minor POA form?

What information do I need to complete the form?

See the Parent Instruction handout for details.

Basic Information:

  • Patient: Name, date of birth, and if you have it, the child’s medical record number
  • Parent Substitutes: Name, address, relationship to the child, and signatures
  • Parent(s) with Legal Custody: Names, addresses and signatures in front of a witness


  • Each Parent’s signature must be witnessed by a person who is at least 18 years old, not related to the parent by blood, marriage or adoption, and not be named as a Parent Substitute.

Additional Documents:

  • If you have sole legal custody, we need a copy of the Court Order to confirm that. Other court documents may be requested as needed.

Does the POA for Treatment of Minor Patient form require signatures of both parents with legal custody?


  • Shared legal custody – BOTH parents with legal custody MUST sign this form
  • Sole legal custody – the parent with sole legal custody must sign AND provide a copy of the Court Order. If there is no Court Order, the mother may provide a photocopy of the child’s birth certificate showing no father has been identified.
  • One parent deceased - mark the box on page one and the surviving parent signs the form.


  • Only one parent with legal custody needs to sign the form in front of a Notary. Minnesota law requires that parent to provide a copy of the form to the other parent within thirty (30) days. Some exceptions apply, such as in the case of a restraining order.


  • There is no specific law. Gundersen requires only one parent with legal custody to sign.

What do I do with the Minor POA form once it is signed?

Keep a copy. Keep at least one (1) copy of the completed form. We recommend you make copies for each parent and each Parent Substitute.

Return the Minor POA form to Gundersen in one of the following ways:

  • If you were provided with a Gundersen Department return envelope, send the completed form to the Gundersen Department assisting you. If the parent has sole legal custody, also include a copy of the required Court Order.
  • You may bring the completed form to the Gundersen Clinic Department where your child receives most of his/her medical care. (If sole legal custody, include a copy of the Court Order.)
  • Send the completed form to Gundersen Health Systems Medical Records Department
    Manager, Patient Record Services
    Gundersen Health System
    Mail Stop AVS-001
    1900 South Avenue
    La Crosse, WI 54601

I have more than one child. Do I have to fill out more than one Minor POA form?

Yes. A separate Minor POA form must be completed for each child and signed by the parents.

How long is the Minor POA form valid?


  • The standard length of time is one (1) year.
  • You may designate a shorter time period by listing specific dates. (i.e. vacation, business trip)
  • If the Parent Substitute is a relative, you may choose to have the Minor POA in effect until the child turns 18 years of age.
  • A “Relative” means a parent, stepparent, brother, sister, stepbrother, stepsister, half brother, half sister, brother-in-law, sister-in-law, first cousin, 2nd cousin, nephew, niece, uncle, aunt, stepuncle, stepaunt, or any person of the preceding generation as denoted by the prefix grand, great, or great-great, whether by blood, marriage, or legal adoption, or the spouse of any person named in this subsection, even if the marriage is terminated by death or divorce. (WI Stats. 48.02(15))
  • If you want a relative to serve as a Parent Substitute for more than one (1) year AND you want to name a second Parent Substitute who is not a relative, you need to complete separate forms.


  • The duration must be one (1) year or less.

How do I revoke the Minor POA form?

While both parents with legal custody must sign a Minor POA form, only one parent needs to revoke the document. Revocation may be given by the parent verbally or in writing. If the parent revokes the Minor POA verbally, the parent should also send Gundersen written notice of revocation as soon as possible to:

  • Manager, Patient Record Services
    Gundersen Health System
    Mail Stop AVS-001
    1900 South Avenue
    La Crosse, WI 54601

Who do I contact if I have questions?

For more information, please call:

  • Patient Information Coordinators
    Gundersen Health System
    Health Information Management
    Mail Stop AVS-001
    (608) 775-5924 or (800) 362-9567, ext. 55924 or (608) 775-0786 or (800) 362-9567, ext. 50786
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