1. Specific Treatment Exclusions: List of any treatments or procedures specifically not authorized, used when patient wishes to exclude certain types of treatment

2. Religious or Cultural Considerations: Specific religious or cultural requirements affecting medical treatment, included when relevant to patient's beliefs

3. Alternative Decision Maker: Appointment of alternative decision maker if primary authorizing party becomes unavailable, used in long-term authorizations

4. Interstate/International Treatment: Additional provisions for treatment across state/international borders, included when patient may require treatment in multiple jurisdictions

5. Interpreter Declaration: Section for interpreter details and declaration, required when authorization is given through an interpreter

1. Schedule A - Medical History: Detailed medical history including allergies, current medications, and pre-existing conditions

2. Schedule B - Specific Treatment Details: Detailed description of authorized treatments, including frequency, duration, and specific procedures

3. Schedule C - Emergency Contacts: List of emergency contacts and their contact details in order of priority

4. Appendix 1 - Advance Care Directives: Copies of any existing advance care directives or living wills

5. Appendix 2 - Supporting Medical Documentation: Relevant medical reports, test results, or specialist recommendations supporting the need for treatment