Colorado Revised Statutes Title 15. Probate, Trusts, and Fiduciaries § 15-18.5-105. Statutory form for certificate of appointment of surrogate decision-makers for health-care benefits

(1) I, (name of attending physician), the attending physician, certify that (name of person for whom decisions are being made) lacks the decisional capacity to make health-care benefit decisions. I further certify that I have made the necessary documentation to the medical record.

(2) I, (name of attending physician), the attending physician or designee, hereby appoint (name of surrogate), (driver's license number or state ID number) as the surrogate decision-maker for health-care benefits on behalf of (name of person for whom decisions are being made), (address, city, state) pursuant to section 15-18.5-104, C.R.S.

(3) (Name of surrogate) 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 (name of person for whom decisions are being made), as provided for in section 15-18.5-104, C.R.S.(Name of surrogate) shall make such decisions in the best interests of (name of person for whom decisions are being made).

Executed this _______ day of _______________ , ____.