Referral for the Public Guardian to Act as Specific Decision Maker for an Adult - Alberta Human Services - Government of Alberta

Referral for the Public Guardian to Act as Specific Decision Maker for an Adult

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The Adult Guardianship and Trusteeship Act (AGTA) outlines that a health care provider may make a referral for the Public Guardian to act as a specific decision maker if:

  • a physician, nurse practitioner or dentist (for dental care only) has determined that the adult does not have the capacity to make a health care decision or a decision about temporary admission to or discharge from a residential facility, and
  • the adult does not have a personal directive with relevant instructions, and/or
  • the adult does not have an agent under a personal directive, guardian or nearest relative to make the decision.

Instructions

  1. Complete the first section with the adult’s information.
  2. Check what type of decision is required and provide a brief description. Only one type of decision – health care, temporary admission to a residential facility, or discharge from a residential facility – can be made on a referral form. If more than one type of decision is needed for the same adult, a separate referral form would be completed. Do not request temporary admission decisions unless there is an identified placement or accommodation.
  3. Complete the checklist to the best of your knowledge.
  4. Provide names and contact information for any known family, friends and/or supports of the Adult who may have knowledge of the adult’s wishes, values and beliefs. When completing the referral form electronically, you can add more sections by clicking on the “+” sign.
  5. Provide the name and contact information, including phone number, of the health care provider that is seeking the decision.
  6. Provide the name and contact information, including phone number, of who the Office of the Public Guardian and Trustee should contact with any questions regarding this referral.
  7. Print, sign and date the form.
  8. Fax the completed form to the Office of the Public Guardian and Trustee that is nearest to the adult’s current location.
Created:
Modified: 2014-11-25
PID: 17684

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