1. Mental Capacity Declaration: Required when proxy access is being granted due to patient's mental capacity issues, including relevant medical professional's assessment

2. Emergency Contact Information: Additional contacts to be notified in case of emergencies or issues with proxy access

3. Time-Limited Access: Specific terms for temporary proxy access with defined trigger events for expiration

4. Multiple Facility Authorization: Required when proxy access needs to cover multiple healthcare facilities or systems

5. Minor Patient Provisions: Special provisions when the patient is a minor, including age-related access transitions

6. Digital Access Credentials: Specific provisions for digital/online access to medical records and portal access

1. Schedule A - Specific Records Access: Detailed list of specific medical records, departments, or information types to which proxy access is granted

2. Schedule B - Healthcare Facilities: List of specific healthcare facilities or systems where proxy access is valid

3. Schedule C - Access Level Matrix: Detailed breakdown of access levels for different types of medical information

4. Appendix 1 - Identification Documents: Copies or details of identification documents provided by both patient and proxy

5. Appendix 2 - Supporting Medical Documentation: Any relevant medical documentation supporting the need for proxy access, especially in cases of mental capacity issues