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1. Identification of Principal: Full legal name and details of the person granting proxy rights
2. Identification of Proxy: Full legal name and details of the appointed healthcare proxy
3. Grant of Authority: Specific powers being granted to the proxy, including scope of medical decisions and access to medical information
4. Duration: Time period for which the proxy appointment is valid and conditions for termination
5. Execution Requirements: Signature blocks and witness/notary requirements as per state law
1. Alternate Proxy: Appointment of backup proxy if primary proxy is unavailable or unable to serve
2. Specific Medical Preferences: Detailed healthcare preferences and instructions to guide proxy decision-making
3. HIPAA Release: Specific authorization for access to medical records and protected health information
1. Medical Preferences Schedule: Detailed list of medical treatment preferences and end-of-life care instructions
2. Contact Information Appendix: Complete contact details for principal, proxy, alternate proxy, and relevant healthcare providers
3. State-Specific Forms: Required state-specific forms and additional documentation as mandated by local law
Healthcare Proxy
Alternate Proxy
Healthcare Provider
Healthcare Facility
Medical Treatment
Healthcare Decision
Capacity
Incapacity
Life-Sustaining Treatment
Medical Records
Protected Health Information
Terminal Condition
Permanent Unconsciousness
End-of-Life Care
Palliative Care
Advance Directive
Revocation
Effective Date
Termination Date
Witnesses
Mental Healthcare
Medical Emergency
Best Interests
Reasonable Care
Scope of Powers
Duration and Effectiveness
Revocation
Successor Appointment
Medical Records Access
Privacy and Confidentiality
Healthcare Preferences
Emergency Powers
Liability and Indemnification
Capacity Determination
Governing Law
Witness Requirements
Severability
Life-Sustaining Treatment
Mental Health Treatment
Anatomical Gifts
Funeral Arrangements
HIPAA Authorization
Reliance Protection
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