Hospital Visitation Authorization Template

Patient Name: [Full Name]
Date of Birth: [Date of Birth]
Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]

Date: [Date]

1. Authorization

I, [Patient Full Name], authorize the following person or persons to visit me during my care, treatment, admission, or stay at a hospital, medical facility, or healthcare setting, subject to applicable facility rules and medical restrictions.

2. Authorized Visitor Information

Authorized Visitor 1 Name: [Full Name]
Relationship to Patient: [Relationship]
Phone Number: [Phone Number]
Email Address: [Email Address]

Authorized Visitor 2 Name: [Full Name]
Relationship to Patient: [Relationship]
Phone Number: [Phone Number]
Email Address: [Email Address]

Additional authorized visitors, if any:

[Insert names and relationships]

3. Primary Contact, if Any

The person I prefer to be treated as my primary visitation contact is:

Name: [Full Name]
Relationship: [Relationship]
Phone Number: [Phone Number]
Email Address: [Email Address]

4. Visitation Instructions

My visitation preferences are as follows:

☐ unrestricted visitation to the extent allowed by facility policy
☐ visitation only during regular visiting hours
☐ visitation at any time for the persons listed above, if allowed
☐ limit visitors to immediate family or listed persons only
☐ no visitors other than those listed in this document
☐ other instructions: [Describe]

Additional instructions, if any:

[Insert details]

5. Restricted or Excluded Persons

The following person or persons are not authorized to visit me, if applicable:

[Full Name]
[Full Name]
[Other details]

If no restriction is intended, write:

[None]

6. Communication Preferences

In addition to visitation, I authorize the facility, to the extent allowed by law and policy, to communicate basic visitation-related information with the following person or persons:

[Insert names]

This document does not by itself authorize medical decision-making unless separately stated in another valid healthcare document.

7. Duration of Authorization

This authorization shall remain effective:

☐ until revoked by me in writing
☐ during my current admission only
☐ until [Date]
☐ until the following event occurs: [Describe]

8. Revocation

I understand that I may revoke or change this authorization at any time, subject to applicable facility procedures and any action already taken in reliance on this document.

Any revocation should be made in writing if reasonably possible.

9. Acknowledgment

I make this authorization voluntarily and intend it to reflect my personal visitation preferences.

I understand that facility safety rules, clinical conditions, emergencies, and applicable law may affect how visitation is carried out.

10. Signature

Patient Signature: __________________________
Name: [Patient Full Name]
Date: [Date]

11. Witness or Notary

Witness Signature, if needed: __________________________
Name: [Full Name]
Date: [Date]

Second Witness Signature, if needed: __________________________
Name: [Full Name]
Date: [Date]

Notary, if required:

State of [State]
County of [County]

On this [Day] of [Month], [Year], before me, the undersigned notary public, personally appeared [Name of Signer], known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that they executed the same for the purposes stated herein.

Notary Public Signature: __________________________
Name: [Notary Name]
My Commission Expires: [Date]