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Documentation Of Self-Sufficient Minor Status (California)

This form documents a self-sufficient minor. The form provided here is simply a sample of what the actual form looks like.


For the purposes of obtaining medical, dental or surgical diagnosis or treatment, pursuant to Family Code §6922, I hereby certify that the following is true:

1. I am fifteen years of age or older,

having been born on ___________, at __________________ (date)

_________________________________________________ (Location)

2. I am living separate and apart from my parents or legal guardian.

_______________________________ (Residence)

_______________________________ (Phone)

_______________________________ (Residence of parents/guardians)

_______________________________ (Phone)

3. I am managing my own financial affairs.

_______________________________ (Name and Address of Employer)

_______________________________ (Other Source(s) of Income)

_______________________________ (Location of Bank Account)

4. I understand that, under the law, I will be financially responsible for my medical, dental, or surgical care and treatment.

________________________________ (Signed)

________________________________ (Date)

© California Medical Association 1999
As a public service of the California Medical Association, reproduction of this document by individuals for personal use and not for commercial purposes is authorized as long as each copy clearly includes this copyright notice.

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