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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:

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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:

Address:

Phone:

(

)

Phone:

(

)

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:

Address:

Phone:

(

)

Phone:

(

)

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)

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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.
		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:

Address:

Phone:

(

)

Phone:

(

)

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:

Address:

Phone:

(

)

Phone:

(

)

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)

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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:

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**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

IRA

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:		/		/
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
	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.

Question	Answer
Form Name	Sdmc Form 200
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	Declarants, opwdd sdmc 200 form, jc sdmc form 300, sdmc form 200

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