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1. Patient Information: Full legal name, date of birth, NHI number, contact details, and address of the patient
2. Healthcare Provider Details: Name, address, and contact information of the primary healthcare provider or facility
3. Emergency Contacts: Names and contact information for primary and secondary emergency contacts
4. General Medical Authorization: Basic authorization for routine medical treatment and emergency care
5. Information Sharing Consent: Authorization for sharing medical information with specified healthcare providers and emergency contacts
6. Duration of Authorization: Specification of how long the authorization remains valid
7. Revocation Rights: Statement explaining the right to revoke the authorization and the process for doing so
8. Signatures: Spaces for patient signature, date, and witness signature
1. Specific Treatment Authorizations: Detailed authorizations for specific procedures or treatments, used when certain procedures are already planned or anticipated
2. Mental Health Treatment Authorization: Specific authorization for mental health treatment, used when mental health care might be needed
3. Religious or Cultural Preferences: Statement of any religious or cultural preferences affecting medical treatment, used when patient has specific cultural or religious requirements
4. Medication Allergies and Restrictions: List of known allergies and medication restrictions, used when patient has specific medical contraindications
5. Alternative Medicine Preferences: Authorization or restrictions regarding alternative medicine treatments, used when patient has specific preferences about alternative treatments
6. Organ Donation Preferences: Statement about organ donation preferences, used when patient wants to specify organ donation wishes
7. Financial Responsibility: Statement regarding payment responsibility and insurance information, used when payment arrangements need to be clarified
1. Schedule A - Authorized Healthcare Providers: List of specific healthcare providers authorized to provide treatment and access medical information
2. Schedule B - Authorized Procedures: Detailed list of specific medical procedures that are pre-authorized
3. Schedule C - Prohibited Treatments: List of specific treatments or procedures that are explicitly not authorized
4. Appendix 1 - Glossary of Medical Terms: Definitions of medical terms used in the authorization form
5. Appendix 2 - Patient Rights Summary: Summary of patient rights under New Zealand law
6. Appendix 3 - Revocation Form: Standard form for revoking the medical authorization if needed
Emergency Contact
Emergency Medical Care
Healthcare Services
Medical Information
Medical Treatment
NHI Number
Patient
Personal Information
Primary Healthcare Provider
Revocation
Routine Medical Care
Specific Medical Procedures
Treatment Authorization
Witness
Medical Records
Capacity
Informed Consent
Healthcare Facility
Confidential Information
Protected Health Information
Next of Kin
Power of Attorney
Advance Directive
Mental Health Treatment
Extraordinary Treatment
Standard of Care
Specialist Services
Alternative Treatment
Authorization Scope
Emergency Treatment
Information Sharing
Privacy and Confidentiality
Duration and Termination
Revocation Rights
Consent
Medical Records Access
Emergency Contact
Healthcare Provider Rights
Patient Rights
Liability
Witness Requirements
Cultural Considerations
Mental Health Treatment
Alternative Treatment
Religious Preferences
Insurance and Payment
Governing Law
Severability
Execution
Healthcare
Medical Insurance
Emergency Services
Aged Care
Mental Health Services
Private Medical Practice
Public Health
Hospital Administration
Ambulance Services
Specialist Medical Services
Legal
Compliance
Medical Records
Patient Services
Emergency Medicine
Risk Management
Privacy and Data Protection
Clinical Operations
Patient Administration
Quality Assurance
Medical Director
Hospital Administrator
General Practitioner
Emergency Room Physician
Nurse Manager
Healthcare Compliance Officer
Medical Records Manager
Patient Services Coordinator
Legal Counsel
Risk Management Officer
Privacy Officer
Clinical Services Manager
Practice Manager
Admissions Coordinator
Emergency Services Director
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