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1. Specific Medical Conditions: Details of any existing medical conditions that require specific consideration or treatment preferences

2. Alternative Representatives: Designation of alternative representatives if the primary representative is unavailable

3. Geographic Scope: Specification if the authorization applies to specific healthcare facilities or geographical areas

4. Religious or Cultural Preferences: Any specific religious or cultural considerations that should influence medical decisions

5. Revocation Clause: Specific terms under which the authorization can be revoked

6. Emergency Contact Information: Additional emergency contacts beyond the authorized representative

1. Identity Documentation: Copies of official identification documents for both the authorizing party and authorized representative

2. Medical History Summary: Brief summary of relevant medical history if applicable to the scope of authorization

3. Witness Attestation Form: Separate form for witness signatures and attestation of the authorization process

4. Healthcare Provider List: List of current healthcare providers and medical facilities if relevant to the authorization