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1. Patient Information: Complete details of the patient including full name, ID number, date of birth, address, and emergency contact information
2. Caregiver Information: Complete details of the designated caregiver(s) including full name, ID number, qualifications, and contact information
3. Scope of Authority: Detailed description of medical decisions and actions the caregiver is authorized to make or take on behalf of the patient
4. Duration of Authority: Specific timeframe for which the permission is valid, including start and end dates if applicable
5. Medical Conditions: List of relevant medical conditions, allergies, and current medications of the patient
6. Emergency Protocols: Specific procedures to follow in case of medical emergencies
7. Confidentiality Agreement: Terms regarding the handling and protection of patient's medical information
8. Signatures and Declarations: Space for all required signatures, including patient/guardian, caregiver, and witnesses
1. Mental Capacity Declaration: Required when the patient has diminished mental capacity, including professional assessment of the patient's ability to make decisions
2. Special Care Instructions: Needed when specific medical procedures or treatments require detailed instructions
3. Alternative Caregiver Designation: Optional section designating backup caregivers in case primary caregiver is unavailable
4. Financial Authority: Optional section detailing any financial responsibilities or authorities granted to the caregiver regarding medical expenses
5. Religious or Cultural Preferences: Required when specific religious or cultural practices need to be observed in medical care
6. Transportation Authorization: Optional section authorizing caregiver to transport patient to medical appointments
1. Schedule A: Medical History: Detailed medical history of the patient including past surgeries, conditions, and treatments
2. Schedule B: Medication Schedule: Complete list of current medications, dosages, and administration schedules
3. Schedule C: Emergency Contacts: Comprehensive list of emergency contacts including medical professionals, family members, and next of kin
4. Schedule D: Caregiver Qualifications: Copies of relevant certifications and qualifications of the caregiver
5. Appendix 1: Medical Facility Preferences: List of preferred hospitals, clinics, and medical practitioners
6. Appendix 2: Insurance Information: Details of medical insurance coverage and relevant policy information
Caregiver
Alternative Caregiver
Medical Treatment
Emergency Care
Healthcare Provider
Medical Decision
Personal Information
Confidential Information
Medical Facility
Legal Guardian
Medical Condition
Treatment Plan
Medication Schedule
Emergency Protocol
Scope of Authority
Healthcare Services
Mental Capacity
Medical Records
Informed Consent
Next of Kin
Witness
Duration of Authority
Medical Emergency
Professional Healthcare Provider
Medical Practitioner
Care Instructions
Personal Care
Medical Expenses
Healthcare Facility
Scope of Authority
Duration
Medical Decision-Making
Emergency Protocol
Confidentiality
Consent
Healthcare Provider Access
Liability and Indemnification
Record Keeping
Data Protection
Termination
Revocation
Dispute Resolution
Governing Law
Amendment
Notification Requirements
Insurance
Financial Responsibility
Force Majeure
Severability
Entire Agreement
Healthcare
Elder Care
Social Services
Medical Insurance
Home Healthcare Services
Disability Care
Child Care
Mental Healthcare
Rehabilitation Services
Legal Affairs
Healthcare Administration
Patient Services
Compliance
Risk Management
Medical Records
Care Coordination
Social Services
Quality Assurance
Clinical Operations
Healthcare Administrator
Medical Social Worker
Care Coordinator
Home Care Manager
Nursing Home Administrator
Patient Care Manager
Legal Compliance Officer
Healthcare Facility Director
Medical Practice Manager
Caregiver Supervisor
Healthcare Legal Advisor
Patient Services Coordinator
Elder Care Specialist
Disability Support Coordinator
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