1. Emergency Contact Information: Additional emergency contacts besides the authorized representative, used when multiple contacts need to be listed

2. Specific Medical Conditions: Details of relevant medical conditions that the representative needs to be aware of, included when authorization is for specific medical circumstances

3. Limitations and Restrictions: Any specific limitations on the representative's authority, included when the authorization is not comprehensive

4. Alternative Representatives: Details of secondary authorized representatives, used when backup representatives are needed

5. Digital Communication Consent: Authorization for electronic communication of medical information, included when digital communications will be used

1. Copy of Patient ID: Attached photocopy or scan of patient's valid government-issued identification

2. Copy of Representative ID: Attached photocopy or scan of authorized representative's valid government-issued identification

3. Proof of Relationship: Documents proving relationship between patient and representative (e.g., birth certificate, marriage certificate) if applicable

4. Medical Power of Attorney: If applicable, existing medical power of attorney documents that support this authorization