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1. Authorized Representative: Details of person authorized to make decisions if patient is incapacitated or unable to do so - used when patient wants to designate a specific decision-maker

2. Specific Treatment Exclusions: List of any procedures or treatments specifically not authorized - included when patient has specific restrictions

3. Religious/Cultural Preferences: Statement of any religious or cultural considerations affecting treatment - used when patient has specific religious or cultural requirements

4. Language Preference: Preferred language for communication and whether interpreter is required - included in multilingual settings

5. Insurance Information: Details of health insurance coverage - included when insurance will be used for payment

1. Schedule A - Authorized Procedures: Detailed list of specific medical procedures authorized

2. Schedule B - Medical History Form: Patient's relevant medical history, allergies, and current medications

3. Appendix 1 - Hospital Policies: Summary of relevant hospital policies and patient rights

4. Appendix 2 - Contact Protocol: Protocol for contacting authorized representatives and emergency contacts