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New Jersey Department of Children and Families Policy Manual




Child Protection and Permanency

Effective Date:













CP&P Form 11-73, Health Care Representative Proxy Directive



Click here to view or print CP&P Form 11-73, Health Care Representative Proxy Directive.



This form is a legal document, completed by adolescents 18 years of age or older, in care or exiting care. It is used by the adolescent to designate someone, 18 years of age or older, to be his or her Health Care Representative, to make medical decisions on the adolescent's behalf, should he or she become incapacitated and unable to make medical decisions for him or herself.



Casework staff should provide this form to adolescents along with a copy of the pamphlet, "Health Care Representative," CP&P Form 11-74.


Casework staff advise the adolescent that he or she may select his or her own Health Care Representative. In order to support the development of lifelong connections to caring adults, casework staff advise the adolescent that his or her Health Care Representative may be a friend, adult sibling, parent, or a relative, but not a staff person of CP&P, DCF, or a provider agency. Similarly, the adolescent's health care provider may not be appointed as the adolescent's Health Care Representative. More than one Health Care Representative may be identified, with one being the Primary and one the Secondary (i.e., an alternate representative), should the Primary be unavailable.


Before the adolescent completes the form, he or she should 1) seek permission from the individual(s) he or she plans to identify as a Health Care

Representative, and 2) discuss with the prospective Health Care Representative(s) his or her medical and health care treatment wishes, should the adolescent become incapacitated.


An appointment of a Health Care Representative must be:


·         Voluntary, in writing, and dated;

·         Signed by the adolescent; and

·         Signed in the presence of two witnesses or a notary public.  CP&P staff may serve as a witness.

The Health Care Representative:


·         Must be at least 18 years old;

·         Makes medical decisions on behalf of the adolescent, should the adolescent become incapacitated. The decisions made by the Health Care Representative cannot be overruled by other family members or a doctor without court intervention;

·         Begins making decisions when two (2) doctors certify, in writing, that the patient (adolescent) is incapacitated, and is no longer able to give consent for his or her own treatment; and

·         Has the legal power to accept or refuse medical treatment for the adolescent; has access to all the adolescent's medical records; and, if death should occur, makes decisions regarding donating organs, authorizing an autopsy, and disposing of the body after death.

The Health Care Representative shall notify the adolescent, the adolescent's legal representative, and any health care providers, if he or she resigns or declines the appointment.


The adolescent may revoke the appointment of a Health Care Representative by doing all of the following:


·         Destroying the declaration document (CP&P Form 11-73);

·         Notifying the Health Care Representative verbally or in writing; and

·         Telling his or her doctor, verbally or in writing, that he or she has revoked the appointment. The revocation is not effective until the doctor is notified.

In addition to choosing a Health Care Representative, the adolescent may also provide instruction and direction regarding his or her wishes about medical care in the event that he or she develops a terminal condition or is permanently unconscious and can no longer make his or her own medical decisions.


The Health Care Representative Proxy Directive, CP&P Form 11-73, becomes effective once:


·         It is transmitted to the adolescent's attending physician or health care institution; and

·         An attending physician and one other doctor confirm, in writing, that the adolescent is unable to make decisions regarding his or her own health care.









Adolescent provides to his or her health care provider




Case record