Who may sign when the patient lacks capacity?

An authorized surrogate specified by an advance directive or a court-appointed guardian may sign. If no document exists, follow state surrogate statutes and facility policy to identify the decision-maker.

Can the form be signed electronically?

Yes. Electronic signatures are valid under the ESIGN Act and UETA when intent, consent, attribution, and retention are satisfied. For consumer-facing medical records, obtain required disclosures when applicable.

Are witnesses or notarization required?

Requirements vary by state and by the document type (DNR, POLST, advance directive). Confirm local rules; some jurisdictions require one or two witnesses or a notary acknowledgment.

How should e-signed forms be stored?

Store signed copies in the EHR with an immutable audit trail showing signer identity, timestamp, and actions. Retain according to HIPAA and applicable state retention rules.

What if family members dispute the decision?

Document the decision-making process, clinician communications, and legal authority. Escalate to risk management and legal counsel per facility policy if disputes arise.

How quickly must the form be made available to care teams?

The signed authorization should be attached to the active medical record and the treating team notified immediately so clinical orders reflect the patient's expressed wishes.

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UGSH CPR Authorization Form

UGSH CPR Authorization Form

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UGSH CPR Authorization Form

Provider Name: Client Name:

WHEREAS

WHEREAS, Provider is qualified and experienced to provide cardiopulmonary resuscitation (CPR) response and related emergency intervention services and training; and

WHEREAS, Client desires Provider to perform CPR services and, where applicable, to authorize Provider personnel to administer emergency CPR to Client's participant(s) under the terms and conditions set forth in this Agreement; and

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein, the parties agree as follows:

SCOPE OF WORK

Provider shall perform the following services for Client (describe required CPR services, training, and emergency response authorization). Client must detail specific expectations, number of covered participants, and any deliverables.

Scope description Number of participants / individuals authorized Location / Facility Scheduled service date

PAYMENT TERMS

Client shall pay Provider fees in consideration for the services described in the Scope of Work. Fees, schedule, and remedies for late payment are set forth below.

Total fee Payment schedule Late payment fee Invoicing and payment method

TERM AND TERMINATION

This Agreement shall commence and remain in effect as set forth below unless earlier terminated in accordance with this Section.

Effective start date Termination / end date Notice period for termination (days)

Either party may terminate this Agreement for material breach by the other party if such breach remains uncured for the notice period set forth above. Provider may suspend services immediately if nonpayment occurs. Termination shall not relieve Client of payment obligations for services performed prior to termination.

PARTICIPANT INFORMATION & MEDICAL AUTHORIZATION

Participant full name Date of birth Emergency contact name and phone Known medical conditions, allergies, or medications

Do Not Resuscitate order applicable? Yes No

CONFIDENTIALITY

Each party shall maintain in confidence all non-public information and records disclosed by the other party that is clearly designated as confidential or that by its nature should reasonably be considered confidential. Confidential information shall not include information that (a) is or becomes publicly available through no breach by the receiving party, (b) was known to the receiving party prior to disclosure by the disclosing party without restriction on use or disclosure, or (c) is independently developed by the receiving party without use of the disclosing party's confidential information.

The receiving party may disclose confidential information to the extent required by law or regulation provided that the receiving party gives prompt written notice to the disclosing party and cooperates reasonably to limit the disclosure.

ACKNOWLEDGMENT AND AUTHORIZATION

Client hereby authorizes Provider and its authorized personnel to administer CPR and related emergency interventions to the named Participant if, in Provider's reasonable medical judgment, such intervention is necessary to preserve life or prevent serious harm. Client understands that CPR may include chest compressions, ventilations, the use of automated external defibrillators, and other emergency measures.

Client represents and warrants that it has disclosed known medical conditions and DNR instructions as required and that it has the authority to grant this authorization. Client releases and agrees to indemnify Provider against claims arising from Provider's good-faith provision of emergency CPR, except in cases of gross negligence or willful misconduct.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state selected by the parties. The parties agree that any dispute arising out of or related to this Agreement shall be resolved in the state and federal courts located within the agreed jurisdiction.

ENTIRE AGREEMENT

This Agreement, including all exhibits and schedules attached hereto, constitutes the entire agreement between the parties concerning the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written. Any amendment or modification to this Agreement must be in writing and signed by authorized representatives of both parties.

NOTICES

Provider notice address Client notice address

CERTIFICATION

By signing below, the undersigned certifies that the information provided in this form is true and complete to the best of their knowledge, that they are authorized to enter into this Agreement on behalf of the party identified, and that they authorize Provider to render CPR consistent with the terms above.

UGSH (Provider) Printed Name:

By:

Date:

Client Printed Name:

By:

Date:

What the UGSH CPR Authorization Form Is and who it affects

The UGSH CPR Authorization Form documents a patient or authorized representative's consent or refusal of cardiopulmonary resuscitation (CPR) and related emergency interventions while under care at a UGSH facility. It captures the patient's decision, legal representative details, and any conditions or limitations on emergency treatment. Clinicians, admitting staff, and legal representatives use the form to guide emergency response and medical orders. Because it affects life-sustaining care, accurate completion, secure storage, and clear signatory authority are essential for clinical, legal, and administrative teams.

Why a clear, complete UGSH CPR Authorization Form matters

A properly completed CPR authorization ensures clinicians act consistently with patient wishes, reduces confusion during emergencies, and creates a dated legal record of consent or refusal that supports clinical decision-making and risk management.

Who typically completes and reviews this form

The UGSH CPR Authorization Form is completed by the patient or an authorized decision-maker and reviewed by clinical staff.

Patients or surrogates who can consent to or refuse life-sustaining treatment.
Physicians and nurses recording orders and verifying medical suitability.
Medical records and risk-management personnel for retention and auditing.

Departments that routinely handle the form include admissions, nursing, risk management, and medical records.

Step-by-step: completing the form at admission or bedside

Follow a clear sequence to confirm identity, document choice, and record authorization to reduce errors and ensure enforceability.

01

Confirm Identity: Verify patient using two identifiers and government ID where available.
02

Discuss Options: Clinician explains implications of CPR and alternative measures.
03

Record Decision: Mark the chosen option, enter effective date, and note any limitations.
04

Sign and File: Obtain required signatures, date, and route to medical record immediately.

Where the completed UGSH CPR Authorization Form goes next

Routing ensures the authorization is visible to treating teams and retained according to health record policy.

Bedside Chart: Place a copy in the active inpatient chart or electronic health record viewable by care teams.
Orders Entry: Clinician enters corresponding medical order in the EHR that mirrors the form's decision.
Medical Records: Scan or attach the signed form to the permanent medical record for retention and auditability.
Risk Management: Send a notice when a refusal or complex decision requires review or legal consultation.

Essential components of a compliant UGSH CPR Authorization Form

A professional form combines clear choices, signer authority, timestamps, witness or notary fields where required, clinical confirmation, and retention instructions.

Patient Decision

A clear, unequivocal selection (consent or refusal) with checkboxes and space for qualifying statements to avoid ambiguity.

Identity Details

Full legal name, date of birth, and medical record number to ensure linkage with the correct clinical chart.

Authority Verification

Fields for representative name, legal relationship, and documentation type (advance directive, durable POA) to establish signing rights.

Clinical Confirmation

Space for physician or nurse to confirm the patient’s medical capacity and the clinical discussion that informed the decision.

Authentication Fields

Lines for signatures, printed names, dates, and witness or notary blocks if state or facility policy requires them.

Retention and Routing

Instructions to file in the EHR, scan into permanent record, and notify care teams and risk management of the form's status.

Data and security elements to include and protect

Patient Identifiers: Name, DOB, MRN, contact

Signature Metadata: Signer name, role, timestamp

Clinical Notes: Capacity assessment summary

Witness Entries: Witness name and signature

Retention Flag: Record retention instructions

Access Controls: Role-based EHR permissions

Common preparation mistakes to avoid

Failing to record the effective date or signing time, which can create disputes about when the instruction began to apply.
Using vague phrasing like 'do not escalate' instead of a specific consent/refusal option, creating clinical uncertainty in emergencies.
Not verifying the signer's authority or attaching supporting legal documents such as a durable power of attorney or court order.
Storing signed paper forms without scanning into the EHR, increasing the risk the order is not available to on-duty clinicians.

Consequences of an incorrect or incomplete authorization

Clinical Risk: Delayed or inappropriate emergency care

Legal Liability: Malpractice or wrongful-death claims

Regulatory Exposure: State licensing inquiries

Recordkeeping Gaps: Audit findings and noncompliance

Disputed Authority: Family conflicts over representative power

Operational Delay: Care team confusion during emergencies

How to configure a digital workflow for this form

Define signer order, required fields, and verification steps before using eSign to ensure clinical and legal requirements are met.

Field	Configuration
Signer Order	Patient/surrogate first, clinician attest second
Required Fields	Decision checkbox, signature, date, witness if required
Authentication	Email plus SMS code or stronger for representatives
Routing	Auto-save to EHR and notify risk management

Technical considerations for electronic completion and submission

Ensure the eSignature platform supports secure signer authentication, audit trails, and EHR attachments.

Integration: EHR attachment supported
Authentication: SMS, Knowledge-Based, or SSO
Audit Trail: IP, timestamp, action log

Comparing eSignature vendor pricing and key compliance features

Select a vendor that meets authentication, audit, and privacy needs; the table compares starting price, trial availability, bulk send, audit trail, HIPAA support, and envelope limits.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no card required	Varies by plan; verify	Varies by plan; verify	Varies by plan; verify	Varies by plan; verify
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No envelope cap; unlimited users included	100 envelopes/user/year limit	Varies by plan; verify	Varies by plan; verify	Varies by plan; verify

Frequently asked questions about the UGSH CPR Authorization Form

Answers to common questions about signer authority, eSigning, witnesses, and record retention to help staff complete and process the form correctly.

Need help? Contact support

Who may sign when the patient lacks capacity?
An authorized surrogate specified by an advance directive or a court-appointed guardian may sign. If no document exists, follow state surrogate statutes and facility policy to identify the decision-maker.
Can the form be signed electronically?
Yes. Electronic signatures are valid under the ESIGN Act and UETA when intent, consent, attribution, and retention are satisfied. For consumer-facing medical records, obtain required disclosures when applicable.
Are witnesses or notarization required?
Requirements vary by state and by the document type (DNR, POLST, advance directive). Confirm local rules; some jurisdictions require one or two witnesses or a notary acknowledgment.
How should e-signed forms be stored?
Store signed copies in the EHR with an immutable audit trail showing signer identity, timestamp, and actions. Retain according to HIPAA and applicable state retention rules.
What if family members dispute the decision?
Document the decision-making process, clinician communications, and legal authority. Escalate to risk management and legal counsel per facility policy if disputes arise.
How quickly must the form be made available to care teams?
The signed authorization should be attached to the active medical record and the treating team notified immediately so clinical orders reflect the patient's expressed wishes.

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