representative to make all such decisions for me except those decisions that I have expressly stated in Part 4 below that I do not authorize him/her to make. If I am able to communicate in any manner, my representative should discuss my health care options with me. My representative should explain to me any choices he or she made if I am able to understand. I further authorize my representative to have all access to and copies of my “personal protected health care information and medical records”. This appointment is effective unless and until it is revoked by me or by an order of a court.
The types of health care decisions I authorize to be made on my behalf include but are not limited to the following:
To consent or to refuse medical care, including diagnostic, surgical, or therapeutic procedures; To authorize the physicians, nurses, therapists, and other health care providers of his/her choice to provide care for me, and to obligate my resources or my estate to pay reasonable compensation for these services; To approve or deny my admittance to health care institutions, nursing homes, assisted living facilities, or other facilities or programs. By signing this form I understand that I allow my representative to make decisions about my mental health care except that he or she cannot have me admitted to a structured treatment setting with 24-hour-a-day supervision and an intensive treatment program – called a “level one” behavioral health facility – using just this grant of authority; To have access to and control over my medical records and to have the authority to discuss those records with health care providers.
4. DECISIONS I EXPRESSLY DO NOT AUTHORIZE my Representative to make for me: