Healthcare SNCD Update

Healthcare SNCD Update

Use this Special Needs Care Directive (SNCD) Update to amend or replace the SNCD on file for the individual named below. Completion and signature of this form authorizes the facility and treating providers to incorporate the updated directives into the patient's medical record and to follow the directives as stated herein.

Patient Information

Date of Birth:    Gender:    Medical Record/ID #:

Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group #:    Subscriber Name:

Current SNCD Status

Is there an existing SNCD on file? Yes No    Date of original SNCD:

Requested Updates to SNCD

Describe changes to the SNCD. Indicate new preferences, restrictions, or instructions. Attach additional pages if necessary.

Medical care preferences / treatment limitations
Mobility / equipment / transportation needs
Communication preferences / accommodations
Medication administration assistance
Personal care / feeding assistance
Behavioral management / de-escalation
Other (specify below)

Proposed Effective Date of Update:    Proposed Expiration Date (optional):

Medical History Summary

Administrative and Legal Provisions

Incorporation and Supersession: Upon acceptance and filing by the provider, this SNCD Update shall be incorporated into the patient medical record and shall supersede any prior SNCD to the extent of any conflict between directives.

Provider Reliance and Limitations: Treating providers and authorized agents may rely on the directives herein when providing care. Providers are not required to follow directives that are inconsistent with applicable law, professionally accepted standards of care, or that would cause a material risk of serious harm to the patient.

Revocation: The patient (or legal representative) may revoke or further amend this SNCD Update at any time by providing a signed, dated written revocation to the custodian of the medical record. Oral revocations must be documented in the medical record in accordance with facility policy.

Confidentiality and Disclosure: By signing this document the patient authorizes disclosure of the updated SNCD to treating providers, care coordinators, designated caregivers, emergency responders, and other entities responsible for implementing the care directives. Disclosures shall otherwise follow applicable privacy laws and institutional policy.

Acknowledgments

Acknowledgment of Understanding: I acknowledge that I have read and understand the contents of this SNCD Update, that I have had the opportunity to ask questions and that my questions have been answered to my satisfaction.

HIPAA Authorization Acknowledgment: I authorize the release and discussion of medical information necessary to implement this SNCD Update to the persons identified as authorized recipients and caregivers on this form or in my medical record.

Acknowledged and Agreed: I acknowledge

Certification

Certification: I certify under penalty of law that the information provided in this SNCD Update is complete and accurate to the best of my knowledge and that I am authorized to make this update. I understand that the health care team will rely on this update when providing care.

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