Hospital power of attorney format model:
Power of Attorney and Commitment Letter of Hospitalization for Inpatients
Department bed number, hospitalization number, patient name, gender, age,
Because I came to the hospital for diagnosis and treatment, according to my own diagnosis and treatment situation and health status, I agree to accept the doctor's advice on? Hospitalization for further treatment? Suggestions.
During my stay in hospital, I entrusted all my medical affairs and related matters, and the scope of authorization was as follows:
1. Truthfully provide the hospital with all the true information about my illness, accept the hospital's inquiries and answers, assist in diagnosis and treatment, accept the doctor's inquiries and sign relevant documents.
2. To understand my illness, authorize me to choose or agree to the diagnosis and treatment plan when I can't make a decision alone.
3. When the patient is incapacitated, the patient's legal representative shall perform his legal rights and obligations on his behalf.
4. The patient's guardian or agent should visit or accompany the patient regularly, understand the condition, pay medical expenses, agree or refuse to use self-funded and expensive drugs or diagnosis and treatment measures, agree or refuse to inject blood and blood products, agree or refuse the operation plan, agree or refuse various medical measures in rescue or operation, and handle other affairs related to the patient. The affairs handled by the agent within the scope of authorization and the medical risks caused by the agent's failure or delay in performing the agency affairs shall be borne by the agent and himself, and have nothing to do with the hospital.
Meanwhile, my client and I promise as follows:
During hospitalization, if the patient leaves the ward without authorization, and there are consequences such as aggravation, deterioration, complications, sudden death, self-injury, suicide, loss, personal injury, attack, accident, and inability to reimburse hospitalization expenses due to leaving the hospital without authorization, the patient shall bear the responsibility himself.
This power of attorney and commitment shall be valid from the date of admission to the date of discharge.
I made the above commitment voluntarily under the condition of completely free choice of hospital.
Patient's signature (handprint): ID number: Address:
Contact telephone number:
Date of signature: year month hour.
Signature of agent (handprint): ID number: address:
Telephone: Relationship with patients:
Date of signature: year month hour.
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Model form of hospital power of attorney Article 2:
Hospital authorization
The patient _ _ _ _ _ _ _ _ _ _ _ _ _ is a special person.
Zhi Zhi Hospital
Trustee:
ID number:
Telephone:
Customer: ID number: Tel:
date month year
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Hospital power of attorney format model article 3:
Patient power of attorney
Client (patient himself): gender and age
Valid ID number: Address:
Trustee: Gender and Age Tel:
Valid ID number: Address: Relationship with patients: □ spouse □ children □ parents □ other close relatives □ colleagues □ friends □
other
I was hospitalized because of illness. During my stay in hospital, I reported illness.
Knowing all the informed consent forms that need to be signed in the process of diagnosis and treatment, I solemnly entrust you as my agent to exercise the right of informed consent during hospitalization and perform the corresponding signing procedures.
The plenipotentiary shall personally sign, and the signature of the client shall be deemed as my signature.
After the client signs the consent form, the consequences will be borne by the patient himself.
Patient's signature: (handprint) MM DD YY.
Signature of the trustee: (handprint) MM DD YY.