2021 Colorado Code
Title 15 - Probate, Trusts, and Fiduciaries
Article 18.5 - Proxy and Surrogate Decision-Makers for Medical Treatment and Health Care Benefit Decisions
§ 15-18.5-105. Statutory Form for Certificate of Appointment of Surrogate Decision-Makers for Health-Care Benefits

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, , the attending physician, certify that lacks the decisional capacity to make health-care benefit decisions. I further certify that I have made the necessary documentation to the medical record. (name of attending physician) (name of person for whom decisions are being made) (2) I, , the attending physician or designee, hereby appoint , as the surrogate decision-maker for health-care benefits on behalf of , pursuant to (name of attending physician) (name of surrogate) (driver's license number or state ID number) (name of person for whom decisions are being made) (address, city, state) section 15-18.5-104 , C.R.S. (3) shall have access to all necessary personal health information as defined by the federal Health Insurance Portability and Accountability Act and any financial information necessary to make appropriate health-care benefit decisions on behalf of , as provided for in shall make such decisions in the best interests of. (Name of surrogate) (name of person for whom decisions are being made) section 15-18.5-104 , C.R.S. (Name of surrogate) (name of person for whom decisions are being made) Executed this day of , . (Attending physician) (Business address) (Business phone) (Business fax)

History. Source: L. 2006: Entire section added, p. 841, § 5, effective May 4.