Healthcare Competency Letter

Healthcare Competency Letter

To:   Date of Request:

Patient Information

Date of Birth:   Gender:

Primary Phone:   Email:

Referral / Assessment Details

Date of Evaluation:   Location / Facility:

License / ID Number:   Contact Phone:

Clinical Findings and Basis for Determination

The clinician conducted a competency assessment using clinical interview, review of medical records, cognitive screening, and collateral information. The clinician's observations and objective findings are summarized below.

Understanding of relevant information about proposed treatment or decision
Appreciation of the significance of the information for one’s own situation
Ability to reason and weigh options and consequences
Ability to communicate a clear and consistent choice
Capacity to manage financial matters (if assessed)

Determination

Based on the assessment and the evidence summarized above, the clinician makes the following determination:

Patient is competent to understand and make informed decisions regarding the specified health matters.
Patient is partially competent; specific limitations and supported decision-making measures recommended below.
Patient is not competent to make the specified health decisions at this time.

Legal and Administrative Statements

This competency determination is a clinical assessment and medical opinion based upon the information available at the time of evaluation. It is intended to inform clinical care and administrative decisions. This document is not a court order and does not itself create or terminate legal rights such as guardianship, power of attorney, or other statutory authorities.

The clinician affirms that the assessment was performed in accordance with applicable professional standards. The clinician may be contacted for clarification using the contact information provided above, consistent with applicable privacy and confidentiality rules.

I authorize the release of this competency determination to the recipient named above for the purpose(s) of treatment planning, administrative decision-making, or as otherwise permitted by law.

Authorization Expiration Date:

I acknowledge that I have received a copy of this competency determination, that the contents have been explained to me in terms I understand, and that I have had the opportunity to ask questions. I understand that I may seek additional evaluation or legal advice regarding the determination.

I acknowledge receipt and understanding of this competency letter.

Additional Notes / Attachments

Cognitive test results
Relevant medical records
Collateral statements
Other (describe below)

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