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Get NY Kaleida Health KH01367-002 2019-2024

Te of Birth Admission/Visit Date Medical Record Number Site Financial Number Patient ID Area ADULT PATIENT WITHOUT CAPACITY/ENABLING A SURROGATE TO CONSENT TO TREATMENT Directions: This form sets forth the steps to enable a surrogate to consent to treatment for an adult patient who lacks capacity. After using this form, the surrogate must sign the applicable consent to treatment form. STEP ONE ENSURE THAT THIS IS THE CORRECT FORM FOR THIS PATIENT (Attending Physician/NP) DO NOT use t.

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