0.2.2 - ci-build

FastAccessControl, published by MITRE. This guide is not an authorized publication; it is the continuous build for version 0.2.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/awatson1978/fhir-access-control-ig/ and changes regularly. See the Directory of published versions

Questionnaire: leap-poahealthcare (Experimental)

Official URL: http://34.94.253.50:8080/hapi-fhir-jpaserver/fhir/Questionnaire/leap-poahealthcare Version: 0.2.2
Active as of 1970-01-01 Computable Name:

Generated Narrative: Questionnaire leap-poahealthcare

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. Questionnairehttp://34.94.253.50:8080/hapi-fhir-jpaserver/fhir/Questionnaire/leap-poahealthcare#0.2.2
... 1GENERAL INFORMATION AND INSTRUCTIONS: Use this questionnaire if you want to select a person, called an agent, to make future health care decisions for you so that if you become too ill or cannot make those decisions for yourself the person you choose and trust can make medical decisions for you. Be sure you review and understand the importance of the document that is created at the end of this process. It is a good idea to talk to your doctor and loved ones if you have questions about the type of health care you do or do not want.0..1group
... 1.1Selection of my Healthcare Power of Attorney and Alternate: I choose the following person to act as my agent to make health care decisions for me.0..1group
... 1.1.1Name0..1string
... 1.1.2Address0..1string
... 1.1.3Home Phone0..1string
... 1.1.4Work Phone0..1string
... 1.1.5Cell Phone0..1string
... 1.2Selection of my Healthcare Power of Attorney and Alternate: I choose the following person to act as an alternate to make health care decisions for me if my first agent is unavailable, unwilling, or unable to make decisions for me.0..1group
... 1.2.1Name0..1string
... 1.2.2Address0..1string
... 1.2.3Home Phone0..1string
... 1.2.4Work Phone0..1string
... 1.2.5Cell Phone0..1string
... 1.3I AUTHORIZE my agent to make health care decisions for me when I cannot make or communicate my own health care decisions. I want my agent to make all such decisions for me except any decisions that I have expressly stated in this form that I do not authorize him/her to make. My agent should explain to me any choices he or she made if I am able to understand. I further authorize my agent to have access to my personal protected health care information and medical records. This appointment is effective unless it is revoked by me or by a court order.0..1boolean
... 1.4Health care decisions that I expressly DO NOT AUTHORIZE if I am unable to make decisions for myself: (Explain or write in "None")0..1string
... 2My specific wishes regarding autopsy0..1group
... 2.1Upon my death, I DO NOT consent to a voluntary autopsy.0..1boolean
... 2.2Upon my death, I DO consent to a voluntary autospy.0..1boolean
... 2.3My agent will give or refuse consent for an autospy0..1boolean
... 3My specific wishes regarding organ donation0..1group
... 3.1I DO NOT WANT to make an organ or tissue donation, and I DO NOT want this donation authorized on my behalf by my agent or my family.0..1boolean
... 3.2I have already signed a written agreement or donor card regarding donation with the following individual or institution.0..1boolean
... 3.2.1Institution Name0..1stringEnable When: 3.2 =
... 3.3I DO WANT to make an organ or tissue donation when I die. Here are my directions0..1boolean
... 3.3.1What organs/tissue I choose to donate.0..1group
... 3.3.1.1Whole body0..1boolean
... 3.3.1.2Any needed parts or organs0..1boolean
... 3.3.1.3Specific parts or organs0..1boolean
... 3.3.1.4Specific part or organs only0..1stringEnable When: 3.3.1.3 =
... 3.3.2I am donating organ/tissue for0..1group
... 3.3.2.1Any legally authorized purpose0..1boolean
... 3.3.2.2Transplant or therapeutic purposes only0..1boolean
... 3.3.2.3Research only0..1boolean
... 3.3.2.4Other0..1boolean
... 3.3.2.5Other purposes0..1stringEnable When: 3.3.2.4 =
... 3.3.3The organization or person I want my organs/tissue to go to are0..1group
... 3.3.3.1My list0..1boolean
... 3.3.3.2List organizations0..1stringEnable When: 3.3.3.1 =
... 3.3.3.3Any that my agent chooses0..1boolean
... 4My specific wishes regarding funeral and burial disposition0..1group
... 4.1Upon my death, I direct my body to be buried.(instead of cremated)0..1boolean
... 4.2Upon my death, I direct my body to be buried in:0..1boolean
... 4.2.1I direct my body to be buried in following:0..1stringEnable When: 4.2 =
... 4.3Upon my death, I direct my body to be cremated.0..1boolean
... 4.4Upon my death, I direct my body to be created with my ashes to be,0..1boolean
... 4.4.1I direct the following to be done with my ashes:0..1string
... 4.5My agent will make all funeral and burial decisions.0..1boolean
... 5Physician Affidavit(Optional) You may wish to ask questions of your physician regarding a particular treatment or about the options in the form. If you do speak with your physician it is a good idea to ask your physician to complete this affidavit and keep a copy for his/her file.0..1group
... 5.1Physicians name0..1string
... 5.2Physicians signature acquired0..1boolean
... 5.3Signature date0..1date
... 6HIPAA WAIVER OF CONFIDENTIALITY FOR MY AGENT0..1group
... 6.1I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164.0..1boolean
... 7MY SIGNATURE VERIFICATION FOR THE HEALTH CARE POWER OF ATTORNEY0..1boolean
... 8If you are unable to physically sign this document, your witness/notary may sign and initial for you. If applicable have your witness/notary sign below. Witness/Notary Verification: The principal of this document directly indicated to me that this Health Care Power of Attorney expresses their wishes and that they intend to adopt it at this time.0..1group
... 8.1Witness or Notary name0..1string
... 8.2Witness or Notary signature acquired0..1boolean
... 9SIGNATURE OF WITNESS I was present when this form was signed (or marked). The principal appeared to be of sound mind and was not forced to sign this form. I affirm that I meet the requirements to be a witness as indicated on page one of the health care power of attorney form.0..1group
... 9.1Witness name0..1string
... 9.2Witness address0..1string
... 9.3Witness signaure acquired0..1boolean

doco Documentation for this format