The Proxy Consent Form is a crucial legal document used in Ireland when an individual needs to delegate decision-making authority to a trusted representative. This delegation may be necessary for future healthcare decisions, personal welfare choices, or specific medical treatments. The form is particularly relevant when planning for potential future incapacity or specific circumstances where direct consent may not be possible. It must comply with the Assisted Decision-Making (Capacity) Act 2015 and other relevant Irish legislation. The document includes detailed information about the scope of authority, the rights and responsibilities of all parties, and specific procedures for activation and revocation. It serves as a vital tool in healthcare planning and personal welfare management, ensuring that an individual's wishes are respected while providing legal protection for all parties involved.
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1. Parties: Identifies the Principal (person granting proxy rights), the designated Proxy (person receiving authority to make decisions), and any alternate Proxies
2. Background: Establishes the context and purpose of the proxy arrangement, and confirms the Principal's current capacity to make this designation
3. Definitions: Defines key terms used throughout the document, including types of decisions covered and relevant medical/legal terminology
4. Appointment and Authority: Formal appointment of the Proxy and detailed description of the decision-making powers being granted
5. Scope of Authority: Specific details of what decisions the Proxy can make and any limitations on their authority
6. Duration and Effectiveness: Specifies when the proxy authority begins and ends, including any triggering events or conditions
7. Proxy's Duties and Responsibilities: Outlines the legal obligations and standards of care required of the Proxy
8. Principal's Rights: States the Principal's continuing rights and ability to revoke the proxy arrangement
9. Revocation Procedure: Details how the proxy arrangement can be terminated or modified
10. Execution: Signature block and witnessing requirements
1. Healthcare Specific Provisions: Additional provisions specifically related to healthcare decisions, required when the proxy authority includes medical decision-making
2. Financial Decisions: Additional provisions for handling financial matters, required when the proxy authority includes financial decision-making
3. Alternative Proxy Provisions: Provisions for appointing and activating alternative proxies, recommended when wanting to ensure continuity of decision-making
4. Emergency Provisions: Special provisions for emergency situations, recommended for healthcare proxy arrangements
5. Conflict Resolution: Procedures for resolving disagreements between multiple proxies or family members, recommended when multiple stakeholders are involved
1. Schedule 1 - Identification Documents: Copies of identification documents for all parties
2. Schedule 2 - Medical Capacity Assessment: If applicable, medical assessment confirming the Principal's capacity to make the proxy appointment
3. Schedule 3 - Specific Authorizations: Detailed list of specific decisions or actions the Proxy is authorized to make
4. Appendix A - Notice of Revocation Form: Standard form for revoking the proxy arrangement
5. Appendix B - Notification Requirements: List of parties to be notified when the proxy authority becomes active or is revoked
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