Sdmc Form 200 PDF Details

The Surrogate Decision-Making Committee (SDMC) Form 200 is a critical document designed for situations where a patient may require a surrogate to make important health decisions on their behalf, emphasizing the need for a thorough and structured process. The form, articulated with detailed instructions not to double-side or staple the documents, spans over five pages and outlines a comprehensive approach towards gathering essential information about the patient, the declarant, and the proposed medical treatments. Starting with the declaration for surrogate decision-making, it captures the declarant’s information and their relationship with the patient, requesting specifics such as names, addresses, and contact details to facilitate smooth communication. It covers various aspects of the patient's current state, including their reaction to proposed treatments, legal surrogates specified under Article 80 of the Mental Hygiene Law, and details about immediate family members. Moreover, the form seeks information on the patient’s medical condition, the necessity for major medical treatments, and the deliberation over the patient's capacity to consent, thereby encapsulating a holistic view towards the decision-making process. The document clarifies the need for complete answers to prevent case processing delays and requires declarants to acknowledge the accuracy and completeness of the information provided, promoting transparency and integrity in surrogate decision-making.

QuestionAnswer
Form NameSdmc Form 200
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesDeclarants, opwdd sdmc 200 form, jc sdmc form 300, sdmc form 200

Form Preview Example

**DO NOT DOUBLE-SIDE FORMS**

**DO NOT STAPLE FORMS**

Page 1 of 5

SURROGATE DECISION-MAKING COMMITTEE

PROCEEDING FOR THE REVIEW OF THE NEED FOR SURROGATE DECISION-MAKING ON BEHALF OF

(Patient’s Name)

(REV. 07/2013)

SDMC FORM 200

DECLARATION FOR

SURROGATE

DECISION-MAKING

Declaration # (SDMC Use Only)

ALL QUESTIONS MUST BE ANSWERED TO PREVENT A DELAY IN PROCESSING THE CASE

To the Surrogate Decision-Making Committee:

1a. I am the Declarant for the above named individual; my name, work address and telephone numbers are:

Name:Title:

Agency/Organization Name:

Full Mailing Address:

(We will contact you regarding this declaration. Please list contact information where you can be reached Monday through Friday, during regular business hours.)

Work Phone (

)

EXT.

Work FAX

(

)

 

Beeper

(

)

 

Work Cell

 

(

)

 

Email

 

 

 

 

1b.

My relationship with the patient is (check all that apply):

 

 

 

 

 

 

 

Direct Care Staff

 

 

Family Care Provider

 

Psychiatrist/Psychologist

 

 

 

 

Social Worker

 

 

Service Coordinator

 

Physician Assistant

 

 

 

 

Case Manager

 

 

Nurse

 

Residence Manager

 

 

 

 

Executive Director

 

 

Physician/Dentist/Podiatrist

 

Other:

 

 

 

 

 

 

 

 

 

 

 

2.Does the patient receive services from any outside OPWDD, OMH, or OASAS organization/agency?

____Yes ____No

If yes, list organization/agency names:

3.Who explained the proposed major medical treatment(s) to the patient? (Title Only)

4.Describe the patient’s reaction when the proposed major medical treatment(s) was/were explained, and any opinions expressed:

**DO NOT DOUBLE-SIDE FORMS**

 

(REV. 07/2013)

**DO NOT STAPLE FORMS**

Page 2 of 5

SDMC FORM 200

5a. Are there any known Legally Authorized Surrogates as specifically identified in Article 80 of the Mental

 

 

 

 

Hygiene Law?

 

 

Yes

 

 

No If yes, check all that apply. _____ Parent _____ Spouse

 

 

 

 

 

 

 

 

 

 

 

_____ Adult Child

 

 

 

Guardian/Conservator/Committee of the Person

 

 

 

Health Care Proxy

 

 

 

 

 

 

 

 

 

 

 

 

5b. Indicate the status of the patient’s mother.

 

 

Living

 

 

 

 

Deceased

 

 

Whereabouts Unknown

 

 

 

 

Indicate the status of the patient’s father.

 

 

Living

 

 

 

 

Deceased

 

 

Whereabouts Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

5c. Provide the following information for anyone living listed above. Explain all of your answers.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

(

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

(

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agree

 

 

 

Disagree

 

 

 

No Opinion

 

 

 

Agree

 

 

 

 

 

 

Disagree

 

 

 

No Opinion

 

 

 

 

Other

 

 

 

 

Does Not Wish to Make Decision

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

Does Not Wish to Make Decision

 

 

 

 

How contacted?

 

 

 

 

Phone

 

 

 

mail

 

 

in person

How contacted?

 

 

 

Phone

 

 

mail

 

in person

Comments:

 

 

 

 

 

 

 

 

 

Unable to contact (see #7)

Comments:

 

 

 

 

 

 

 

 

Unable to contact (see #7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

(

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

(

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agree

 

 

 

Disagree

 

 

 

No Opinion

 

 

 

Agree

 

 

 

 

 

 

Disagree

 

 

 

No Opinion

 

 

 

 

Other

 

 

 

 

Does Not Wish to Make Decision

 

 

 

Other

 

 

 

 

 

Does Not Wish to Make Decision

How contacted?

 

 

 

 

Phone

 

 

 

mail

 

 

in person

How contacted?

 

 

 

Phone

 

 

mail

 

in person

Comments:

 

 

 

 

 

 

 

 

 

Unable to contact (see #7)

Comments:

 

 

 

 

 

 

 

 

Unable to contact (see #7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**DO NOT DOUBLE-SIDE FORMS**

 

(REV. 07/2013)

**DO NOT STAPLE FORMS**

Page 3 of 5

SDMC FORM 200

6a.

Are there any known actively involved adult siblings, or other family members, who are unavailable, do

 

not wish to make the decision or are not authorized to make the decision?

 

 

 

 

 

Yes

 

No

If yes, list below.

 

 

 

 

6b.

Are there any correspondents, community advocates or a FAMILY CARE PROVIDER?

 

 

 

 

 

Yes

 

No

If yes, list below.

6c. For current or former OPWDD patients ONLY: If the patient has one or more actively involved sibling or other adult family member explain why surrogate decision-making is needed (e.g.: family members are unavailable, family members do not wish to make the decision and/or they want SDMC to resolve a possible objection or difference of opinion). Explain all of your answers.

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

(

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

Phone:

(

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agree

 

Disagree

 

 

No Opinion

 

 

 

 

Agree

 

Disagree

 

 

No Opinion

 

 

 

 

 

Other

 

 

 

Does Not Wish to Make Decision

 

 

 

 

Other

 

 

 

Does Not Wish to Make Decision

How contacted?

 

 

 

Phone

 

 

mail

 

in person

How contacted?

 

 

 

 

Phone

 

 

mail

 

in person

 

 

 

 

 

 

 

 

 

Comments:

 

 

 

 

 

 

 

Unable to contact (see #7)

Comments:

 

 

 

 

 

 

 

 

Unable to contact (see #7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

(

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

Phone:

(

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agree

 

Disagree

 

 

No Opinion

 

 

 

 

Agree

 

Disagree

 

 

No Opinion

 

 

 

 

 

Other

 

 

Does Not Wish to Make Decision

 

 

 

 

Other

 

 

Does Not Wish to Make Decision

How contacted?

 

 

 

Phone

 

 

mail

 

in person

How contacted?

 

 

 

 

Phone

 

 

mail

 

in person

Comments:

 

 

 

 

 

 

 

Unable to contact (see #7)

Comments:

 

 

 

 

 

 

 

 

Unable to contact (see #7)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
(Name of Physician/ Dentist/Podiatrist)

**DO NOT DOUBLE-SIDE FORMS**

 

(REV. 07/2013)

**DO NOT STAPLE FORMS**

Page 4 of 5

SDMC FORM 200

7.For persons listed in sections 5 and 6 who were not able to be contacted, please list what efforts were made to contact them to discuss this case.

8.As the Declarant, I have read SDMC Form 210 (Certification on Capacity) that has been completed by

 

and signed on

(Name of Psychiatrist or Psychologist)

 

 

(Date)

indicating his/her professional opinion that the patient does not have the capacity to provide informed consent for the proposed major medical treatment(s).

9.The proposed major medical treatment(s) is/are as follows (per SDMC Form 220-A, #4a and 4b):

10.

Is the use of general anesthesia anticipated?

 

 

Yes

 

No (per SDMC Form 220-A, #7)

 

 

 

11.

Is an HIV test being requested?

 

Yes

 

 

 

No

(per SDMC Form 220-A, #5)

 

 

 

 

12.As the Declarant, I have read SDMC Form 220-A (Certification of Need for Major Medical Treatment) that has been completed by

and signed ondescribing the patient’s medical/dental condition, the proposed

(Date)

major medical treatment(s), the risks, benefits and alternative(s) to the proposed procedure.

13.In my opinion, the patient cannot give informed consent for this procedure because:

14.In my opinion, the proposed major medical treatment(s) is/are in the best interest of the patient because:

**DO NOT DOUBLE-SIDE FORMS**

**DO NOT STAPLE FORMS**

15.This declaration is made on behalf of:

a. Patient’s Name:

Address:

Phone: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Phone Number of Patient’s Residence)

c. Type of Residence:

 

 

 

 

ICF

 

CR

 

 

 

 

 

 

 

DC

 

 

FC

 

 

 

 

IRA

 

 

CW

 

 

PC

 

 

Hospital Psychiatric Ward

 

 

 

 

 

 

Nursing Home

 

 

 

 

 

Adult Home

 

 

 

 

 

 

 

 

Assisted Living

 

 

 

 

Waiver Services

 

 

 

 

 

 

OMH funded or approved housing

Other:

d. County of Residence:

 

(REV. 07/2013)

Page 5 of 5

SDMC FORM 200

b. Date of Birth:

 

/

 

/

 

 

 

 

 

(Month

 

Day

 

Year)

Age:

 

 

 

 

Sex: ______ Male ______ Female

Religion:

Primary Language:

Does the patient have special communication needs?

________Yes _______No

 

 

 

If Yes, what type:

 

foreign language

 

communication board or other assistive device

 

sign language interpreter

 

other

 

 

16. Name of Second Contact:

 

Title:

(An alternate contact to Declarant must be provided.)

Second Contact’s Full Mailing Address (Organization Name):

Street

 

 

 

City

 

State

Zip

Work Phone (

)

EXT.

 

 

 

 

 

 

 

 

FAX Phone

(

)

 

 

 

Beeper

 

(

)

 

 

 

Work Cell

(

)

 

 

 

Email

 

 

 

 

 

 

 

17.To the best of my knowledge, the above information and statements are truthful and complete.

Print Declarant’s Name Clearly

Declarant’s Signature

Date

NOTE: This form must be dated the same or later than the other SDMC Forms in the case.

Sdmc Form 200 isn’t the one you’re looking for?

Related Documents