Certification Of Incapacity Form PDF Details

Certification of Incapacity is a document that states the incapacity and mentally state of an individual. This document allows for someone to legally make decisions on behalf of another person who cannot do so themselves, such as in the case when someone becomes incapacitated due to Alzheimer's Disease or other form of dementia. Certification Of Incapacity Form provides all necessary information for this documentation process and helps you understand what needs to be done if your loved one becomes incapacitated.

This basic report will aid you to find out the time it will take you to complete certification of incapacity form, how many pages it's got, and a few additional specific specifics of the file.

QuestionAnswer
Form NameCertification Of Incapacity Form
Form Length1 pages
Fillable?Yes
Fillable fields32
Avg. time to fill out6 min 43 sec
Other namessample letter of incompetence from doctor, letter of incompetence from doctor template, letter of incapacitation, certificate of incapacity form

Form Preview Example

PHYSICIANS’ CERTIFICATION OF

INCAPACITY TO MAKE AN INFORMED DECISION

I.Certification of the Attending Physician

I, ____________________, M.D., as the Attending Physician, have examined

__________________________ (Patient) on ________________ (Date) at _____________

(Time). Based on that examination, I find that ________________ (Patient) is incapable of

making an informed decision about the provision, withholding, or withdrawing of the following medical treatment:

.

Because of the Patients condition, which includes: ___________________________________

_____________________________________________________________________________,

the Patient is unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment, and ( ) is unable to make a rational evaluation of the burdens, risks, and benefits of the treatment, or course of treatment or ( ) is unable to communicate a decision. (Check One) This attestation has ( ) has not ( ) been made within two (2) hours of examining this Patient.*

Date: ___________________

__________________________________

 

Signature of Attending Physician

 

__________________________

 

Time of Signature

II.Certification of a Second Physician

I, _______________________, M.D., have examined __________________________

(Patient) on _________________ (Date) at _________(Time). Based on that examination, I find

that ____________________________ (Patient) is incapable of making an informed decision

about the provision, withholding, or withdrawing of the following medical treatment:

______________________________________________________________________________

_____________________________________________________________________________.

Because of the Patients condition, which includes: ___________________________________

_____________________________________________________________________________,

the Patient is unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment, and ( ) is unable to make a rational evaluation of the burdens, risks, and benefits of the treatment, or course of treatment or ( ) is unable to communicate a decision. (Check One) This attestation has ( ) has not ( ) been made within two (2) hours of examining this Patient.

Date: ___________________

__________________________________

 

Signature of Physician

 

__________________________

 

Time of Signature

*One of these certifications must be made within this two (2) hour time frame.

Copyright, 2014, Ober, Kaler, Grimes & Shriver

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sample letter of incompetence from doctor fields to fill out

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Entering details in sample letter of incompetence from doctor stage 2

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