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1. Identification of Parties: Details of the person granting proxy consent (the grantor), the designated proxy decision-maker, and any alternate proxies
2. Declaration of Capacity: Statement confirming the grantor's mental capacity and voluntary execution of the document at the time of creation
3. Scope of Authority: Detailed description of the medical decisions and healthcare matters the proxy is authorized to make decisions about
4. Duration of Authority: Specification of when the proxy consent becomes effective and when it terminates
5. Proxy's Obligations: Description of the proxy's duties and standard of care in making decisions
6. Execution: Formal requirements for signing, witnessing, and dating the document
1. Specific Medical Conditions: Include when the proxy consent relates to specific known medical conditions or treatments
2. Religious or Cultural Preferences: Include when specific religious or cultural considerations should guide medical decisions
3. Emergency Contact Information: Include when additional emergency contacts beyond the proxy need to be specified
4. Revocation Clause: Include when specific conditions for revocation need to be outlined beyond standard legal provisions
1. Schedule A - Medical History: Optional schedule containing relevant medical history and current conditions of the grantor
2. Schedule B - Specific Treatments: List of specific medical treatments or procedures for which proxy consent is explicitly granted or withheld
3. Appendix 1 - Identification Documents: Copies of identification documents for all parties involved
4. Appendix 2 - Medical Provider Information: List of current healthcare providers and medical facilities regularly used by the grantor
Healthcare
Legal Services
Medical Insurance
Elder Care
Mental Health Services
Hospital Administration
Social Services
Healthcare Education
Medical Research
Legal
Compliance
Medical Administration
Patient Services
Risk Management
Ethics Committee
Clinical Operations
Medical Records
Social Services
Quality Assurance
Medical Director
Hospital Administrator
Legal Counsel
Healthcare Compliance Officer
Patient Rights Advocate
Medical Social Worker
Clinical Director
Risk Management Officer
Healthcare Attorney
Medical Records Manager
Nursing Director
Ethics Committee Member
Healthcare Facility Manager
Patient Services Coordinator
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