Healthcare Incapacitation Form

HEALTHCARE INCAPACITATION FORM

Purpose: This form designates an individual to make healthcare decisions and receive protected health information in the event the patient is determined to be incapacitated. By completing and signing this document, the patient declares the facts and grants the authorities and limitations set forth below. This designation becomes effective only upon a qualified professional's determination of incapacity as described in Section IV. The patient retains the right to revoke or amend this designation at any time while competent.

I. Patient Information

Date of Birth:   Gender:

II. Emergency Contact

III. Insurance & Coverage (if applicable)

IV. Incapacity Determination

Incapacity becomes operative when a licensed treating physician or two licensed physicians, one of whom is the treating physician, certify in writing that the patient lacks capacity to make or communicate informed healthcare decisions. Certifying clinician(s): . Date of determination:

The patient directs that incapacity be determined according to the applicable standard of incapacity under state law and facility policy. If incapacity is disputed, the patient requests timely review by an independent clinician.

V. Designation of Healthcare Agent

I designate the following person to act as my healthcare agent with the authority set forth below if and when I am determined incapacitated:

Scope of Authority (select applicable items)

  Consent to, refuse, or discontinue medical or surgical treatment (including dialysis, blood transfusion, and medication).
  Make decisions regarding life-sustaining treatment, including cardiopulmonary resuscitation and ventilator support.
  Consent to mental health evaluation and treatment.
  Arrange for placement, care providers, transfer or discharge from facilities.
  Access my medical records and receive all protected health information necessary to make decisions.
  Other (describe in Special Instructions)

VI. Medical History & Current Conditions

VII. HIPAA AUTHORIZATION & RELEASE

I expressly authorize all healthcare providers and institutions to disclose my protected health information, including medical records, test results, diagnosis, prognosis, and treatment information, to my designated healthcare agent to the extent necessary for the agent to make or carry out healthcare decisions on my behalf.

This authorization includes the release of information related to mental health treatment, communicable diseases, and substance use disorder treatment where permitted by law. I understand that the information disclosed pursuant to this authorization may be redisclosed by the recipient and no longer protected by federal privacy regulations to the extent allowed by law.

VIII. SPECIAL INSTRUCTIONS / LIMITATIONS

IX. REVOCATION AND ACKNOWLEDGMENT

I understand that I may revoke this designation at any time while I am competent by providing written notice to my treating providers and to the designated agent. Revocation is effective upon receipt by the provider or agent. If a court determines this document is invalid under applicable law, I understand the court may appoint a decision-maker consistent with governing law.

I acknowledge that I have read and understand this Healthcare Incapacitation Form and that the choices I make here reflect my intent and directions regarding the designation of a healthcare agent and access to my health information.

Check to signify acknowledgment:

X. AUTHORITY OF AGENT AFTER INCAPACITY

The agent's authority includes making decisions that are consistent with my expressed wishes, or, if my wishes are unknown, decisions based on my best interest. The agent must act in good faith, keep records of decisions, and, where practicable, consult with family members and treating clinicians. The agent does not have authority to make decisions that are specifically restricted in this form or by law.

XI. OPTIONAL — ATTORNEY-IN-FACT / GUARDIAN INFORMATION

If this document is executed by a legal guardian, conservator, or attorney-in-fact on behalf of the patient, provide relationship and legal authority below.

XII. NOTICES

Notice: This document is intended to operate under the laws governing advance healthcare directives, incapacity determinations, and privacy of health information. It is recommended that copies be provided to the designated agent, primary care provider, and facilities where care is received. The patient understands that this form does not replace a legal durable power of attorney unless explicit authority is granted and recognized by applicable law.

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