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1. Patient Information: Full legal name, date of birth, address, and insurance details of the patient
2. Family Member/Authorized Representative Information: Details of the family member(s) being granted consent authority, including their relationship to the patient
3. Scope of Authority: Clear outline of what medical decisions the family member(s) are authorized to make, including any limitations
4. Duration of Authority: Specification of how long the consent authority remains valid, including any expiration dates or conditions
5. Medical Information Access: Details of what medical information the authorized family member(s) can access and under what circumstances
6. Emergency Provisions: Specific provisions for emergency situations where immediate medical decisions are required
7. Revocation Rights: Information on how and when the patient can revoke the consent
8. Data Protection Statement: GDPR-compliant statement regarding the handling of personal and medical data
9. Signatures and Declarations: Space for formal signatures of all parties and any required witness attestations
1. Hierarchy of Decision Makers: Used when multiple family members are given different levels of authority or when establishing an order of priority
2. Special Medical Conditions: Include when there are specific medical conditions that require special consideration or treatment preferences
3. Digital Communication Consent: Optional section for consenting to digital/electronic communication of medical information
4. Translation Declaration: Required when the form needs to be used in multiple languages or with non-German speaking parties
5. Mental Capacity Statement: Include when there are concerns about future mental capacity or existing conditions affecting decision-making
1. Schedule A: Specific Treatments Consent: Detailed list of specific medical treatments or procedures that are pre-approved or specifically excluded
2. Schedule B: Healthcare Providers List: List of healthcare providers and facilities where the consent is to be used
3. Appendix 1: Identification Documents: Copies of required identification documents for all parties
4. Appendix 2: Family Relationship Proof: Documentation proving the family relationship between patient and authorized representative(s)
Healthcare
Medical Services
Elder Care
Residential Care
Hospital Services
Mental Health Services
Rehabilitation Services
Emergency Medical Services
Family Medicine
Legal Services
Legal
Compliance
Patient Administration
Medical Records
Quality Assurance
Risk Management
Patient Relations
Emergency Services
Social Services
Data Protection
Medical Director
Hospital Administrator
Legal Compliance Officer
Patient Relations Manager
Healthcare Facility Manager
Medical Records Officer
Data Protection Officer
Admissions Coordinator
Family Liaison Officer
Healthcare Attorney
Clinical Risk Manager
Quality Assurance Manager
Emergency Department Coordinator
Ward Manager
Social Services Coordinator
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