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 consent form for the medical treatment of my child?

Parents are not always available to take their children to their medical appointments, for example if they are on vacation or are at work. Gundersen cannot legally provide non-emergency care to a minor patient (under age 18) if a parent or legal guardian is not present unless a parent has granted permission.

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) and/or legal guardian(s):

  • Authorize direct patient care for a child by Gundersen if a parent or legal guardian is not present.
  • 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.
  • Authorize Gundersen to release and discharge the patient from the Hospital into the custody of the parent substitute.

The parent(s) or legal guardian(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 consent form has not been signed?

No. Stepparents are not considered legal guardians. If a consent form has not been signed, we must contact a parent or legal guardian before providing non-emergency care.

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

Yes. A healthcare provider may legally treat a minor 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 consent form?

Gundersen POA for Treatment of Minor Patient Forms is available in the following departments:

  • Pediatric Clinic
  • Family Medicine
  • Pediatrics in the Hospital
  • Pediatric ICU
  • Trauma & Emergency Center (TEC)
  • Any Gundersen Regional Clinic
  • Download a PDF of the form here

What information do I need to complete the form?

The consent form includes basic information such as the patient’s name and date of birth, name(s), address (es) and signature(s) of the appointed parent substitute(s), and contact information for the parent(s) and/or legal guardian(s). For each of the parent(s) and/or legal guardian(s) signature, a witness will also need to sign the consent form.

Does the POA for Treatment of Minor Patient form require both custodial parents signature?

Due to changes in the state laws, both custodial parents are required to sign the POA for Minor form to appoint a parent substitute. A witness is also required to sign the consent form.

Can only one parent sign the POA for Treatment of Minor Patient form?

Only if that parent has sole legal custody. You will need to provide a copy of the court document that identifies that parent as having sole legal custody.

What do I do with the consent form once it is signed?

After carefully reading and signing the consent form, return it to the Pediatric Clinic, Family Medicine, Pediatrics in the Hospital, Pediatric ICU, TEC or any Gundersen Regional Clinic.

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

Yes. A separate consent form must be completed and signed for each child.

How long is the consent form valid?

The parent (s) and/or legal guardian(s) can determine the length the consent form is valid, however, it cannot exceed one year. After the form has expired, a new form must be signed and returned to Gundersen.

The parent(s) and/or legal guardian(s) can also revoke the consent at any time by sending a written notice to:

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

If both custodial parents sign the POA for Treatment of Minor Patient form, we need only one custodial parent to revoke the signed form.

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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