1. Medical Condition Summary: Brief description of the relevant medical condition - include when the authorization is for specific medical condition-related decisions

2. Financial Authorization: Details of any financial decisions or transactions the representative is authorized to make - include when financial matters are part of the scope

3. Travel Authorization: Specific permission for travel-related medical decisions - include when the sick person may require medical care while traveling

4. Privacy Waiver: Explicit authorization to access medical records and discuss medical information - include when access to medical records is needed

5. Revocation Clause: Terms under which the authorization can be revoked - include when the authorization is for an extended period

1. Schedule A - Specific Medical Procedures: List of specific medical procedures or treatments the representative is authorized to approve or decline

2. Schedule B - Healthcare Providers: List of relevant healthcare providers and their contact information

3. Appendix 1 - Identity Documents: Copies of identity documents of both parties (may be required by healthcare providers)

4. Appendix 2 - Medical History Summary: Brief medical history relevant to the authorization (optional but can be helpful for healthcare providers)