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1. Specific Medical Conditions: Details of particular medical conditions requiring special consideration, used when the authorization is condition-specific

2. Emergency Contact Information: Additional emergency contacts besides the authorized representative, included when multiple contact points are needed

3. Healthcare Provider Information: Specific healthcare providers or facilities covered by the authorization, used when authorization is limited to certain providers

4. Special Instructions: Any specific instructions or limitations regarding medical treatments or procedures, included when there are specific preferences or restrictions

5. Alternative Representative: Details of an alternative representative if the primary representative is unavailable, used when backup authorization is needed

1. List of Authorized Healthcare Providers: Schedule listing specific healthcare providers or facilities covered by the authorization

2. Medical History Summary: Brief summary of relevant medical history that may impact decision-making

3. Specific Treatments Authorization: Detailed list of specific treatments or procedures that are pre-authorized or explicitly excluded

4. Identity Verification Documents: Copies of identity documents for patient and authorized representative