1. Alternate Decision Maker: Designation of person authorized to make medical decisions if patient becomes incapacitated

2. Special Medical Conditions: List of existing medical conditions, allergies, or specific health concerns that may affect treatment

3. Religious or Cultural Preferences: Specific religious or cultural considerations that may affect medical treatment

4. Organ Donation Authorization: Optional section for expressing wishes regarding organ donation

5. Translation Certificate: Required when the document is prepared in multiple languages or for non-English speaking patients

1. Schedule A - Medical History: Detailed medical history of the patient including past surgeries, medications, and chronic conditions

2. Schedule B - Specific Procedures: Detailed description of specific medical procedures being authorized, if applicable

3. Schedule C - Insurance Information: Complete details of medical insurance coverage and policy information

4. Appendix 1 - Glossary of Medical Terms: Definitions of medical terms used in the authorization for patient understanding

5. Appendix 2 - Hospital Policies: Relevant hospital policies and procedures that affect patient care and treatment