1. Specific Treatment Authorizations: Detailed list of specific procedures or treatments being authorized, used when authorization is needed for particular medical procedures

2. Mental Health Authorization: Specific authorization for mental health treatment decisions, required when mental health care may be needed

3. Religious or Cultural Preferences: Statement of religious or cultural considerations that should be taken into account in medical treatment

4. Revocation Clause: Specific terms under which the authorization can be revoked before the end date

5. International Travel Authorization: Additional authorization for medical treatment while traveling internationally, including passport details if relevant

1. Schedule 1: List of Authorized Medical Procedures: Detailed list of specific medical procedures and treatments covered by the authorization

2. Schedule 2: Medical History Summary: Brief summary of relevant medical history, allergies, and current medications

3. Appendix A: Privacy Statement: Detailed privacy notice explaining how medical information will be handled and protected

4. Appendix B: Identification Documents: Copies of identification documents for both the patient and authorized representative