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OTHER NAMES Medical Visitation Authorization Hospital Visitation Authorization Form

What is a Hospital Visitation Authorization?

If you want to make sure someone can visit you in the hospital, you may need a Hospital Visitation Authorization. Oftentimes non-family members can be prevented from making hospital visits, but having a signed authorization can help you avoid any complications. A Hospital Visitation Authorization helps you bypass red tape so your friends can support you in person. 
 
Planning for worst case scenarios isn't always pleasant, but a Hospital Visitation Authorization can be very important. Hospitals have strict rules and, much of the time, only family can visit patients. Furthermore, states can use a very narrow definition of family. What if you want your partner to be able to visit? What about your boyfriend or best friend? You have your own definition of family, but you have to make sure the hospital knows about it - and it's in writing. If everyone your authorizing has a copy of the document it can help make tough situations a little easier. A Hospital Visitation Authorization helps make sure your visitors can make it.

When to use a Hospital Visitation Authorization:

  • You want to make sure certain people can visit you in the hospital.
  • You have a partner or significant other, but aren't legally married.

Sample Hospital Visitation Authorization

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Hospital Visitation Authorization

 

I, , a resident residing at , , County, State of , do hereby give notice and authorization that if I should be injured or fall ill or be incapacitated through any other cause that necessitates my hospitalization or treatment in a medical facility, it is my wish that be given first preference in being admitted to visit me in such medical or treatment facility, whether or not there are parties related to me by blood or by law or other parties desiring to visit me, unless and until I freely give contrary instructions to competent medical personnel on the premises involved.

 

 

Executed this ____day of _____________, 20___.

 

Signature: ___________________________________ Date: _________

 

Name:

 

Address: , ,

 

 

Witnesses Signatures:

 

Witness #1

 

Signature: ___________________________________ Date: _________

 

Name:

 

Address: , ,

 

 

Witness #2

 

Signature: ___________________________________ Date: _________

 

Name:

 

Address: , ,

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