C.R.S. § 15-18.5-105 Statutory Form For Certificate of Appointment of Surrogate Decision-Makers For Health-Care Benefits

• Library: Colorado Statutes
• Edition: 2023
• Currency: Current through 2023 Regular and 1st Extraordinary Session
• Year: 2023
• Citation: C.R.S. § 15-18.5-105

The following statutory form for certificate of appointment of surrogate decision-maker for health-care benefits is legally sufficient:

CERTIFICATE OF APPOINTMENT OF A SURROGATE DECISION-MAKER FOR HEALTH-CARE BENEFITS

(1) I, (name of attending physician), the attending physician, certify that (name of person for whom decisions are being made) lacks the decisional capacity to make health-care benefit decisions. I further certify that I have made the necessary documentation to the medical record.

(2) I, (name of attending physician), the attending physician or designee, hereby appoint (name of surrogate), (driver's license number or state ID number) as the surrogate decision-maker for health-care benefits on behalf of (name of person for whom decisions are being made), (address, city, state) pursuant to section 15-18.5-104, C.R.S.