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Patient Forms

by: SMCMAMay 7, 2014
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Common Authorization Forms for treatment of minors and release of medical information

Forms for Disputes with Physicians

End-of-Life Forms

Common Authorization Forms

Authorization for Agent to Consent to Medical Treatment of a Minor
This form allows you, as the parent or legal guardian, to temporarily appoint another individual as your Agent, to make health care decisions for the child. The appointment lasts only up to 60 days, and is intended for situations such as when a parent is temporarily out of state and the minor child is remaining with a family member or family friend.

Authorization for Release of Medical Information
This form authorizes your healthcare provider to release your private medical records to the parties you specify.

Authorization to Transfer Medical Records
This form authorizes your health care provider to transfer your private medical records to the health care provider you specify.

Request for Patient Access to Medical Records
This form is used to request access to your medical records from your health care provider.


Disputes with Physicians

If you have a dispute with a physician over fees, insurance, or ethics/conduct, if that physician is a member of the SMCMA, you can opt to have your dispute reviewed by one of SMCMA’s peer review committees. Please note, all recommendations by SMCMA peer review committees are advisory only. We cannot review your complaint if a lawsuit has been undertaken or if it involves a Workers’ Compensation matter.

SMCMA Peer Review Request Form

While the SMCMA will attempt to mediate this dispute, it has no authority to take action against a physician’s license. The Medical Board of California is the only authority in the state that may take disciplinary action against the license of the physician who is the subject of your complaint. The toll-free number of the Medical Board is 1-800/633-2322, and the Medical Board is located at 1426 Howe Avenue, Sacramento, CA 95825-3236. Click here to make your complaint online.


End-of-Life Forms

POLST

POLST stands for Physician Order for Life-Sustaining Treatment. It is a physician order that gives patients more control over their end-of-life care. Produced on a distinctive bright pink form and signed by both the physician and patient, POLST specifies the types of medical treatment that a patient wishes to receive towards the end of life.

POLST form in English

POLST form in Spanish

 

Advance Directive Healthcare Kit

In California, Advance Health Care Directives are the legally recognized format for “living wills.” An Advance Health Care Directive enables individuals to make sure that their health care wishes are known in advance and considered if for any reason they are unable to speak for themselves. An advance directive also allows a patient to appoint a health care "agent" who will have legal authority to make health care decisions in the event that patient is incapacitated, or immediately upon appointment if the patient expressly grants such authority.

The California Medical Association (CMA) produces an Advance Directive Healthcare Kit that includes legal forms and wallet identification cards, and answer many of the most frequently asked questions about these issues. The cost to the public is $6. Click here to purchase a copy.


DNR Form

A DNR (Do Not Resuscitate) Form (actual title: “Emergency Medical Services Pre-Hospital Do Not Resuscitate (DNR) Form) is an official State document developed by the California EMS Authority and the California Medical Association which, when completed correctly, allows a patient with a life threatening illness or injury to forgo specific resuscitative measures that may keep them alive. These measures include: chest compressions (CPR), assisted ventilation (breathing), endotracheal intubation, defibrillation, and cardiotonic drugs (drugs which stimulate the heart). The form does not affect the provision of other emergency medical care, including treatment for pain (also known as “comfort measures”), difficulty breathing, major bleeding, or other medical conditions. Many patients make their DNR wishes officially known because they do not want to be placed on life-assisting equipment in the event that their heart or breathing ceases.

Click here for the DNR form in PDF format. The completed form must be signed by both patient and physician, and both must retain a copy. Additionally, a DNR medallion or bracelet cab help facilitate prompt identification of the patient and avoid the problem of lost or misplaced forms. A copy of the DNR form is required to purchase such a medallion from one of the approved providers.


DNR Medalions

A DNR medallion is a metal or permanently imprinted insignia, worn by a patient, that has been manufactured and distributed in accordance with State of California "Emergency Medical Services Authority Criteria for Selection of Medallion/Bracelet/Necklace for DNR Purposes" as defined in the "Guidelines for EMS Personnel Regarding Do-Not-Resuscitate (DNR) Directives," and is imprinted with the words "Do-Not-Resuscitate, EMS." There are currently two (2) California Approved Medallion Providers.  approved to produce Statewide approved pre-Hospital DNR medallions:

MedicAlert Foundation
www.medicalert.org
1-888-633-4298

Caring Advocates
www.caringadvocates.org
1-800-647-3223