SECTION 1. Chapter 112 of the General Laws, as appearing in the 2004 Official Edition, is hereby amended by adding the following new section:

Section 12 ½ MEDICAL TREATMENT AND CONSENT

(a)    A parent, legal guardian, or legal custodian of a minor may authorize an adult person or persons (“caregiver”) to

1)      consent to medical, surgical, dental, developmental, mental health, or other treatment  for the minor under the supervision or upon the advice of a physician, nurse, dentist, mental health, or other health care professional licensed to practice in this Commonwealth;

2)      exercise  parental rights to obtain records and other information with regard to  health care services and insurance provided to the minor; and

3)      make educational decisions on behalf of the minor and in all other ways stand in for the parent, legal guardian or legal custodian with respect to federal, state and district educational policy.  Examples of educational decisions include, but are not limited to, the following: accessing the minor’s  educational records; representing the minor in enrollment, disciplinary, curricular, special education, or other educational matters; signing permission slips for school activities; and any other decision that facilitates the minor’s educational experience.

4)      provided there is no prior order of any court in any jurisdiction currently in effect

that would prohibit the parent, legal guardian, or legal custodian from exercising     the power that  the parent, legal guardian, or legal custodian seeks to confer upon the caregiver. 

(b)   “Caregiver” is defined as a person who is at least 18 years of age and with whom the child currently resides. 

(c)    Granting of authority under this section shall not divest the parent or parents of any parental or guardianship rights, but shall confer upon the caregiver concurrent authority with respect to the minor.

(d)   The parent, legal guardian, or legal custodian may only grant to the caregiver those powers which he himself possesses.

The provisions of subsection (a) shall not be used by a parent, legal guardian or legal custodian to confer upon a caregiver the power to make medical or educational decisions on behalf of a minor if such power has been assigned by Federal or State law to the minor.

(e)    Authorization may be conveyed by any written form containing the following information: (i) the name of the parent, legal guardian, or legal custodian; (ii) the name of the caregiver;  (iii) the name and date of birth of the minor or minors;  (iv) a statement by the parent, legal guardian or legal custodian that there are no court orders presently in effect that would prohibit him from exercising the power that he seeks to confer upon the caregiver; and (v)  a description of the categories of authority being conferred. The authorization shall be signed by the parent, legal guardian, or legal custodian in the presence of two witnesses who are at least 18 years of age, neither of which may be the caregiver. The authorization also shall be signed by the caregiver, who shall attest to being at least 18 years of age and that the child currently resides with the caregiver.

(f)     The medical or educational decision of a caregiver pursuant to authorization under this section shall be superseded by any contravening oral or written decision of the parent, legal guardian or legal custodian.

(g)    A grant of authority under this section may be amended or revoked at any time through a writing signed by the parent that originally granted authority to the caregiver.  The writing that amends or revokes the grant of authority must be filed with those persons who received notice of the previous grant of authority.

(h)    A person who relies on a written instrument that is consistent with the requirements of this section, without actual knowledge of facts contrary to those stated in the authorization form or of a contravening decision by the child’s parent, legal guardian or legal custodian, shall not incur any criminal or civil liability for doing so and has no obligation to make any further inquiry or investigation. Nothing in this section shall relieve any individual from liability for other provisions of the law.   Furthermore, nothing in this section shall relieve professionals licensed under chapter 112 of the General Laws for violations of any applicable law or regulation for failure to meet the standard of care when providing treatment in accordance with any such written instrument.

(i)      The Department of Public Health (DPH) shall be charged with designing and disseminating the authorization form below to all of the appropriate medical care facilities licensed in the Commonwealth.  Individual medical care facilities shall be responsible for ensuring that the authorization form is available and accessible to people who would benefit from its use.

(j)     The Department of Education (DOE) shall be charged with designing and disseminating the authorization form below to all of the appropriate educational facilities licensed in the Commonwealth.  Individual educational facilities shall be responsible for ensuring that the authorization form is available and accessible to people who would benefit from its use.

(k)   The authorization must be either notarized or sworn to under pains and penalties of perjury.  The form must also be substantially in the following form, except that the use of alternative language consistent with the statute shall not be precluded:

Medical and Educational Consent Authorization Form

I.  What this form enables: (language directly from the statute)

A parent, legal guardian, or legal custodian of a minor may authorize an adult person or persons (“caregiver”) to:

• consent to medical, surgical, dental, developmental, mental health, or other treatment  for the minor under the supervision or upon the advice of a physician, nurse, dentist, mental health, or other health care professional licensed to practice in this Commonwealth;
• exercise  parental rights to obtain records and other information with regard to  health care services and insurance provided to the minor;; and
• make educational decisions on behalf of the minor and in all other ways stand in for the parent, legal guardian or legal custodian with respect to federal, state and district educational policy.  Examples of educational decisions include, but are not limited to, the following: accessing the minor’s educational records; representing the minor  in enrollment, disciplinary, curricular, special education, or other educational matters; signing permission slips for school activities; and any other decision that facilitates the minor’s  educational experience.

II.  Steps to delegate authority:

1.  I, [name], am the parent of the child(ren) listed below and there are no court orders now in effect that would prohibit me from exercising the power that I wish to confer upon the caregiver.

2.  (Only necessary if you are the child’s legal guardian or legal custodian): I, [name], am the legal guardian or legal custodian of the child(ren) by court order (copy attached) and there are no other court orders in effect that would prohibit me from exercising the power that I wish to confer upon the caregiver3.  I, [name], wish to be the caregiver of the child(ren) listed below.  I am at least 18 years of age and the minor child(ren)   currently live with me.

4.  I, [name of parent or legal guardian or legal custodian], do hereby give to [name of caregiver], residing at [caregiver’s address], the power to make medical and educational decisions for the following child(ren):

Name                                                               Date of Birth    

____________________                                ____________________________

____________________                                ____________________________

____________________                                ____________________________

The power that I give is specifically limited to health care, mental health care, and educational decision-making, and it may only be exercised by the person named above as caregiver.

The caregiver named above may NOT:

(please list specifically any decisions related to health care, mental health care, or educational decision-making that you do NOT wish to delegate to the adult caregiver.)

I give the power to consent freely and knowingly in order to provide for the child(ren) and not as a result of pressure, threats, or payments by any person or agency.

This document shall remain in effect until it is revoked by me by notifying my child(ren)’s medical, mental health care and insurance providers, school district administrators, and the caregiver named above, in writing.

I hereby affirm that the above statements are true, under pains and penalties of perjury.

 Printed name:

Signature:

Signature of caregiver who is being given power to consent:

Witness No. 1 signature:

Witness No. 1 printed name and address:

Witness No. 2 signature:

Witness No. 2 printed name and address:

III. Explanations

TO PARENT, LEGAL GUARDIAN, OR LEGAL CUSTODIAN:

You may authorize any adult or adults to make medical and educational decisions on behalf of your child(ren). You should convey only those powers that you wish the caregiver to share with you. Authorization does not in any way limit your own right to make decisions on behalf of your child(ren). You may revoke this authorization in writing, and you may override, orally or in writing, any individual decision made by a caregiver. 

TO CAREGIVER:

This authorization form authorizes you to make, on behalf of the child(ren) named above, only those decisions specified by the child(ren)’s parent, legal guardian or legal custodian. You need not obtain the consent of the child(ren)’s parent, legal guardian, or legal custodian before making a decision, but you may not knowingly make a decision that conflicts with the decision of the child(ren)’s parent, legal guardian or legal custodian.

TO SCHOOL OFFICIALS:

No person who acts in good faith reliance upon a consent letter to provide educational decision-making authority without actual knowledge of facts contrary to those stated on the affidavit, may be subject to criminal liability or to civil liability to any person, or is subject to professional disciplinary action, for such reliance if the applicable portions of this form are completed. 

TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:

No person who acts in good faith reliance upon a consent letter to provide medical, surgical, dental, developmental screening and/or mental health examination or treatment, without actual knowledge of facts contrary to those stated on the affidavit, is subject to criminal liability or to civil liability to any person, or is subject to professional disciplinary action, for such reliance if the applicable portions of this form are completed.