Nursing Home Affidavit of Authorization
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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