Child Custody Affidavit

Child Custody Affidavit

Proof of Medical Desicion Making
Date of Affidavit *

MonthDayYear
Date of Visit
Hour MinutesAM/PM Option
Verification of Custodial Status and Medical Decision-Making Authority for Child

As part of our commitment to providing the highest standard of psychiatric care at Faisal Rafiq MD. PC., DBA Psychvisit, we require verification of custody and medical decision-making authority for all minor patients under our care.

This is to ensure that we are compliant with legal requirements and that the appropriate consents are obtained for the treatment of Child.

Required Documentation:

Proof of Custody:

A copy of the court order or legal document that establishes you as the custodial parent or legal guardian of Child.
This document should clearly indicate your authority to make decisions regarding the child's welfare, including medical and mental health treatment.

Proof of Authority to Make Medical Decisions:

If you are not the biological parent, please provide documentation that specifically grants you the authority to make medical decisions on behalf of Child.
This may include legal guardianship papers or a medical power of attorney.
Process:

Please submit the requested documents to our office at your earliest convenience.

Upon receipt and verification of these documents, we will proceed with the appropriate care for Your Child.. Please note that failure to provide the necessary documentation may delay or prevent the provision of medical treatment.

Confidentiality:

Be assured that all information provided will be treated with the utmost confidentiality and used solely for the purpose of verifying custodial and decision-making authority as per medical and legal requirements.

If you have any questions or need further assistance, please do not hesitate to contact our office at 631-440-1010.
Child's Name*

First NameLast Name
Child's Date of Birth:*

MonthDayYear
Date of Birth
Parent or Guardian That has Proof of Medical Decision Making for the child:*

First NameLast Name
Parent's or Guardian's Date of Birth:*

MonthDayYear
Date of Birth
Mobile Phone Number*
Please enter a valid phone number.
Required Documentation (Upload here)*

Documents Proving Medical Decision Making
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Acknowledgment and Consent::*

By signing below, I, the parent or guardian, acknowledge that I am the legal custodian and/or possess the necessary authority to make medical decisions for my child I understand that this authorization is required for the provision of medical and psychiatric care by Faisal Rafiq MD. PC DBA Psychvisit and that any false statements or misrepresentations may have legal implications.
Signature of Parent (By Signing you State that the Above is True and Factual)*

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