STATE OF [Your State]

COUNTY OF [Your County]

I, [Your Name], of legal age, and currently the [Your Job Title] at [Your Company Name], located at [Your Company Address], being duly sworn, depose and say:

1. Authority and Responsibility:

As [Your Job Title] at [Your Company Name], I possess the authority to make declarations and execute authorizations concerning the residents under our care. Our facility is fully licensed and adheres to the regulatory standards mandated by [Your State] for the operation of nursing care facilities.

2. Resident Identification:

I hereby affirm that [Your Client Name], who was admitted to our facility on [Admission Date], is a resident in good standing at [Your Nursing Home Name]. The resident is identified by the following details: Date of Birth [DOB], Social Security Number [SSN], and previous residence address [Previous Address].

3. Purpose of Authorization:

This affidavit formally grants authorization to [Name of Individual/Entity] to act as a representative for [Your Client Name] in matters that require explicit consent and legal or financial decision-making. The specific areas of authorized activity include:

• Medical Decisions

  • Granting [Name of Individual/Entity] the authority to consent to medical treatments that are deemed necessary by healthcare providers.

  • Enabling access to [Your Client Name]'s medical records for the purposes of healthcare coordination and treatment planning.

  • Authorizing communication with healthcare providers to discuss treatment options, receive updates, and make informed decisions on behalf of [Your Client Name].

• Financial Transactions

  • Authority to oversee and manage [Your Client Name]'s financial accounts related to their care.

  • Execution of banking transactions including but not limited to withdrawals, transfers, and deposits as necessary to meet the costs of care and other related expenses.

  • Handling of all billing and payment processes associated with [Your Client Name]'s residency and care services at [Your Nursing Home Name].

• Legal Representations

  • Authorization to represent [Your Client Name] in legal matters such as court proceedings, contractual negotiations, and the settlement of disputes.

  • Power to engage with legal counsel and participate in discussions that impact the welfare and rights of [Your Client Name].

This authorization is comprehensive and includes the ability to make decisions that significantly affect the health, financial well-being, and legal rights of [Your Client Name].

4. Verification of Authority:

Prior to granting these extensive powers, [Name of Individual/Entity] has undergone a rigorous verification process to confirm their identity and legal capacity to act responsibly and effectively on behalf of [Your Client Name]. This process included:

• Identity Verification: Confirming the identity of [Name of Individual/Entity] through government-issued identification.

• Capacity Assessment: Assessing the legal capacity of [Name of Individual/Entity] to ensure they understand and can undertake the responsibilities involved.

• Compliance Checks: Ensuring that all actions undertaken will be in compliance with state laws and align with the policies and ethical standards established by [Your Nursing Home Name] regarding resident representation and advocacy.

5. Liability and Responsibility:

This affidavit delineates the scope of responsibility accepted by [Name of Individual/Entity] in representing [Your Client Name]. It confirms that:

• Acceptance of Responsibility: [Name of Individual/Entity] agrees to uphold their duties in the best interests of [Your Client Name], adhering strictly to the guidelines and limitations outlined in this document.

• Best Interest Commitment: All actions taken will prioritize the health, financial security, and legal rights of [Your Client Name].

• Limitation of Liability: [Your Nursing Home Name] will not hold liability for any actions that extend beyond the authorized scope described herein. It is understood that [Name of Individual/Entity] assumes responsibility for any repercussions stemming from unauthorized actions.

6. Duration of Authorization:

The authorization granted through this affidavit remains effective unless revoked or amended by a subsequent legal document executed in accordance with the laws of [Your State]. Any such changes will be documented and retained in the resident’s file at [Your Nursing Home Name].

7. Execution:

This affidavit is executed to provide a lawful and binding authorization concerning the care and representation of [Your Client Name], ensuring that all actions taken by [Name of Individual/Entity] are recognized and enforceable under the law.

SWORN TO AND SUBSCRIBED before me this [Month Day, Year].

[Your Job Title]

[Your Company Name]

Notary Public:

State of [Your State]

My commission expires [MM-DD-YYYY].

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