Supported Decision-Making Authorization (Form 1) - Alberta Human Services - Government of Alberta

Supported Decision-Making Authorization (Form 1)

Albertans who are capable of making personal decisions but need some assistance can designate a family member or friend to help them make and communicate decisions. The adult can give their supporter legal permission to access relevant personal non-financial information by completing and signing a Supported Decision-making Authorization.

Instructions

Write in your name and the date you would like the authorization to come into effect.

1. Termination of Previous Supported Decision-making Authorization

If you already have a Supported Decision-making Authorization in place, this section allows you to terminate or replace it with a new one. If you have never written a Supported Decision-making Authorization form, proceed to section 2.

2. Appointment of Supporter(s)

You have the option to designate one to three supporters. You are not required to have more than one supporter. List the name of your supporter(s) and initial each name. Think about a person or people whom you trust and whether this person(s) can help you make decisions. You will need to have your witness initial each name as well.

3. Decisions respecting personal matters for which supporter(s) has authority

You can identify which personal matters are included in the authorization and which supporter(s) has authority over each matter. This will allow you to be clear when different supporter(s) are named for different personal matters. You and your witness must initial each area of personal decision-making for which the supporter(s) has authority.

4. Authority of supporter(s)

For this section, you need to think about what authority you want your supporter to have and how they can best support your decision-making and communication needs. Because you are capable of making decisions, you will always have the final say. The supporter’s role is to assist you, but it is important to know that by granting a supporter access to your personal information, it will authorize health care staff (health information custodians and others) who have personal and health information about you to disclose that information to your supporter for the purposes of helping them assist you in making decisions.

By consenting to full disclosure of your personal and health information to your supporter, you consent that you are aware that they may have access to sensitive information about you and you will not have control over how they use or protect that information. However, you may terminate (end) your consent at any time by completing Form 2.

Note: There may be a period of delay between you terminating your consent and the supporter being denied access to your information.

5. Effective dates of supported decision-making authorization

This section lets you determine the date on which the authorization will come into effect. This could mean on the date that you complete the authorization or at a date in the future. The end date can be filled in if you want to limit the time your supporter will assist you. If you want the supporter to assist you for an extended or undetermined period of time, you do not need to add an end date. You can terminate the authorization at any time by filling out Form 2 if you no longer want the person to act as a supporter.

6. Consent of Supporters

This optional section allows the person you name as supporter(s) to consent to their role. The more your supporter(s) knows ahead of time, the better informed they will be to carry out your wishes. Please note that your supporter(s) must be at least 18 years of age or older.

7. Signature

Your signature is required. You must sign and date your Supported Decision-making Authorization in front of a witness. Your witness cannot be one of your supporters. You and your witness must include your addresses and the location where you signed the document.

Note: Your witness should also initial anywhere you have initialed.

Please keep your signed and witnessed original form in a safe place that others can access when needed. Many people freely choose to give a copy of their authorization to their designated supporters, physicians and service providers so they can be informed ahead of time and can be aware of what is expected of them. For more information, contact our office toll free at 1‑877‑427‑4525.

Collection of Personal Information

The personal information required on these forms is collected pursuant to s. 33 (a) and (c) of the Freedom of Information and Protection of Privacy Act and the Adult Guardianship and Trusteeship Act (AGTA) and its associated regulations (AR 219/2009 & 224/2009). Your personal information will be used for purposes related to the administration of the AGTA and its regulations. Your information will not be further used or disclosed without your permission unless authorized or required by law. If you have any questions about the collection of your personal information, please contact: Administrator, Office of the Public Guardian, Alberta Human Services, 4th Floor, Standard Life Centre, 10405 Jasper Avenue, Edmonton, AB T5J 4R7 or by telephone at 1‑877‑427‑4525.

Created:
Modified: 2017-12-20
PID: 16532

Contact this service

1-877-427-4525 (toll-free)

8:15 am - 4:30 pm (Monday to Friday, closed statutory holidays)