Chapter 1: Taking Control of Your Healthcare

Appendix I

Designation of My Healthcare Advocate and Alternate

I, _____________________________________, currently living at (address)_________________________________________________________________wish to delegate (full name)_________________________________________, as my healthcare advocate and (full name) ________________________________as my alternate advocate, (address)_________________________________________________________. I understand that my advocate (and alternate) have responsibilities and functions different from my healthcare proxy who only makes healthcare decisions on my behalf were I to lack the capacity to make such decisions on my own.

I have thoroughly discussed the functions/responsibilities I would like my advocate to assist me with, and he/she agrees to carry them out to the best of his/her abilities. The functions and responsibilities I would like my advocate (or my alternate if my primary is not available) to follow through with the following functions and responsibilities:

1. Discuss my current diagnosis, treatment, prepared tests, procedures, and surgery, with all my current doctors, specialists and all other health professionals involved in my current and future care. My advocate can have access to all my current and future healthcare records in my doctors’ offices, in the hospital and all other facilities (for example, nursing home).
2. Serve as the communication liaison between all of my healthcare providers and specific family members and friends who wish to have this information. Attached is a list of family members and friends and their contact information with whom my advocate can share my healthcare information. I have informed all those listed of my advocate (alternate) and the role he/she will carry out.
3. If I am a patient in the hospital or another facility, my advocate (or alternate) has my permission to stay either in or outside my room 24 hours/7days a week or as much time as possible in keeping with the rules of the facility. My advocate can ask my doctors and staff about the medications, intravenous and other fluids I am being given; inquire about tests/procedures and results, and be given all information regarding my transition home, to another part of the hospital or facility. My advocate will also serve as my advisor but not make decisions regarding all of the above issues.
4. Should I become incapacitated and no longer have the capacity to make medical decisions on my own behalf, then my advocate will discuss everything regarding my current condition with my medical proxy (or alternate). My proxy (or alternate) will make medical decisions on my behalf and if relevant, end of life decisions in conformity with my living will. Were I to regain my capacity to make healthcare decisions on my own behalf (as determined by my primary coordinating physician and, if required, by a second physician, then my healthcare advocate (or alternate) would resume the above noted responsibilities and roles.
5. My advocate can accompany me and attend any or all office visits I have with my healthcare providers. He/she has my permission to take notes during these visits and/or tape record all discussions (if my healthcare provider permits) so all treatment recommendations can be accurately carried out.
6. The responsibilities and roles of my advocate will begin on the date this agreement is signed by me, my advocate, and alternate and will be witnessed. This agreement will remain in force until such time that I decide to change to another advocate and/or change the role and responsibilities of my advocate.