ORS 127.736
Form of declaration


A declaration for mental health treatment shall be in substantially the following form:

I, ___________________, being an adult of sound mind, willfully and voluntarily make this declaration for mental health treatment. I want this declaration to be followed if a court or two physicians determine that I am unable to make decisions for myself because my ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that I lack the capacity to refuse or consent to mental health treatment. “Mental health treatment” means treatment of mental illness with psychoactive medication, admission to and retention in a health care facility for a period up to 17 days, convulsive treatment and outpatient services that are specified in this declaration.

If I become incapable of giving or withholding informed consent for mental health treatment, I want these decisions to be made by: (INITIAL ONLY ONE)
__ My appointed representative consistent with my desires, or, if my desires are unknown by my representative, in what my representative believes to be my best interests.
__ By the mental health treatment provider who requires my consent in order to treat me, but only as specifically authorized in this declaration.
If I have chosen to appoint a representative to make mental health treatment decisions for me when I am incapable, I am naming that person here. I may also name an alternate representative to serve. Each person I appoint must accept my appointment in order to serve. I understand that I am not required to appoint a representative in order to complete this declaration.
I hereby appoint:
NAME _________
ADDRESS _________
TELEPHONE # _________
to act as my representative to make decisions regarding my mental health treatment if I become incapable of giving or withholding informed consent for that treatment.
If the person named above refuses or is unable to act on my behalf, or if I revoke that person’s authority to act as my representative, I authorize the following person to act as my representative:
NAME _________
ADDRESS _________
TELEPHONE # _________
My representative is authorized to make decisions that are consistent with the wishes I have expressed in this declaration or, if not expressed, as are otherwise known to my representative. If my desires are not expressed and are not otherwise known by my representative, my representative is to act in what he or she believes to be my best interests. My representative is also authorized to receive information regarding proposed mental health treatment and to receive, review and consent to disclosure of medical records relating to that treatment.

This declaration permits me to state my wishes regarding mental health treatments including psychoactive medications, admission to and retention in a health care facility for mental health treatment for a period not to exceed 17 days, convulsive treatment and outpatient services.
If I become incapable of giving or withholding informed consent for mental health treatment, my wishes are: I CONSENT TO THE FOLLOWING MENTAL HEALTH TREATMENTS: (May include types and dosage of medications, short-term inpatient treatment, a preferred provider or facility, transport to a provider or facility, convulsive treatment or alternative outpatient treatments.)







I DO NOT CONSENT TO THE FOLLOWING MENTAL HEALTH TREATMENT: (Consider including your reasons, such as past adverse reaction, allergies or misdiagnosis. Be aware that a person may be treated without consent if the person is held pursuant to civil commitment law.)







ADDITIONAL INFORMATION ABOUT MY MENTAL HEALTH TREATMENT NEEDS: (Consider including mental or physical health history, dietary requirements, religious concerns, people to notify and other matters of importance.)







YOU MUST SIGN HERE FOR THIS DECLARATION TO BE EFFECTIVE:
______________________
(Signature/Date)
I affirm that the person signing this declaration:

(a)

Is personally known to me;

(b)

Signed or acknowledged his or her signature on this declaration in my presence;

(c)

Appears to be of sound mind and not under duress, fraud or undue influence;

(d)

Is not related to me by blood, marriage or adoption;

(e)

Is not a patient or resident in a facility that I or my relative owns or operates;

(f)

Is not my patient and does not receive mental health services from me or my relative; and

(g)

Has not appointed me as a representative in this document.
Witnessed by:
______________ ____________
(Signature of Witness/ (Printed Name of Witness)
Date)
______________ ____________
(Signature of Witness/ (Printed Name of Witness)
Date)
I accept this appointment and agree to serve as representative to make mental health treatment decisions. I understand that I must act consistently with the desires of the person I represent, as expressed in this declaration or, if not expressed, as otherwise known by me. If I do not know the desires of the person I represent, I have a duty to act in what I believe in good faith to be that person’s best interest. I understand that this document gives me authority to make decisions about mental health treatment only while that person has been determined to be incapable of making those decisions by a court or two physicians. I understand that the person who appointed me may revoke this declaration in whole or in part by communicating the revocation to the attending physician or other provider when the person is not incapable.
______________ ____________
(Signature of (Printed name)
Representative/Date)
______________ ____________
(Signature of Alternate (Printed name)
Representative/Date)
This is an important legal document. It creates a declaration for mental health treatment. Before signing this document, you should know these important facts:
This document allows you to make decisions in advance about certain types of mental health treatment: psychoactive medication, short-term (not to exceed 17 days) admission to a treatment facility, convulsive treatment and outpatient services. Outpatient services are mental health services provided by appointment by licensed professionals and programs. The instructions that you include in this declaration will be followed only if a court or two physicians believe that you are incapable of making treatment decisions. Otherwise, you will be considered capable to give or withhold consent for the treatments. Your instructions may be overridden if you are being held pursuant to civil commitment law.
You may also appoint a person as your representative to make treatment decisions for you if you become incapable. The person you appoint has a duty to act consistently with your desires as stated in this document or, if not stated, as otherwise known by the representative. If your representative does not know your desires, he or she must make decisions in your best interests. For the appointment to be effective, the person you appoint must accept the appointment in writing. The person also has the right to withdraw from acting as your representative at any time. A “representative” is also referred to as an “attorney-in-fact” in state law but this person does not need to be an attorney at law.
This document will continue in effect for a period of three years unless you become incapable of participating in mental health treatment decisions. If this occurs, the directive will continue in effect until you are no longer incapable.
You have the right to revoke this document in whole or in part at any time you have not been determined to be incapable. YOU MAY NOT REVOKE THIS DECLARATION WHEN YOU ARE CONSIDERED INCAPABLE BY A COURT OR TWO PHYSICIANS. A revocation is effective when it is communicated to your attending physician or other provider.
If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. This declaration will not be valid unless it is signed by two qualified witnesses who are personally known to you and who are present when you sign or acknowledge your signature.
Under Oregon law, a person may use this declaration to provide consent for mental health treatment or to appoint a representative to make mental health treatment decisions when the person is incapable of making those decisions. A person is “incapable” when, in the opinion of a court or two physicians, the person’s ability to receive and evaluate information effectively or communicate decisions is impaired to such an extent that the person currently lacks the capacity to make mental health treatment decisions. This document becomes operative when it is delivered to the person’s physician or other provider and remains valid until revoked or expired. Upon being presented with this declaration, a physician or provider must make it a part of the person’s medical record. When acting under authority of the declaration, a physician or provider must comply with it to the fullest extent possible. If the physician or provider is unwilling to comply with the declaration, the physician or provider may withdraw from providing treatment consistent with professional judgment and must promptly notify the person and the person’s representative and document the notification in the person’s medical record. A physician or provider who administers or does not administer mental health treatment according to and in good faith reliance upon the validity of this declaration is not subject to criminal prosecution, civil liability or professional disciplinary action resulting from a subsequent finding of the declaration’s invalidity.

[1997 c.563 §3 (enacted in lieu of 127.735)]

Source: Section 127.736 — Form of declaration, https://www.­oregonlegislature.­gov/bills_laws/ors/ors127.­html.

127.002
Definitions for ORS 127.005 to 127.045
127.005
When power of attorney in effect
127.015
Revocation of power of attorney
127.025
Authority under power of attorney recognizable regardless of date of execution
127.035
Limitations on liability of person reasonably relying on power of attorney
127.045
Duty of agent under power of attorney
127.505
Definitions for ORS 127.505 to 127.660
127.507
Capable adults may make own health care decisions
127.510
Appointment of health care representative and alternate health care representative
127.515
Execution
127.520
Persons not eligible to serve as health care representative
127.525
Acceptance of appointment
127.527
Form for appointing health care representative
127.529
Form of advance directive
127.532
Appointment
127.533
Duties
127.535
Authority of health care representative
127.540
Limitations on authority of health care representative
127.545
Revocation of advance directive or health care decision
127.550
Petition for judicial review of advance directives
127.555
Designation of attending physician or health care provider
127.560
Provisions not exclusive
127.565
Independent medical judgment of provider
127.570
Mercy killing
127.575
Instrument presumed valid
127.580
Presumption of consent to artificially administered nutrition and hydration
127.625
Providers under no duty to participate in withdrawal or withholding of certain health care
127.635
Withdrawal of life-sustaining procedures
127.640
Physician to determine that conditions met before withdrawing or withholding certain health care
127.642
Principal to be provided with certain care to insure comfort and cleanliness
127.646
Definitions for ORS 127.646 to 127.654
127.649
Health care organizations required to have written policies and procedures on providing information on patient’s right to make health care decisions
127.652
Time of providing information
127.654
Scope of requirement
127.658
Effect of ORS 127.505 to 127.660 on previously executed advance directives
127.660
Short title
127.663
Definitions for ORS 127.663 to 127.684
127.666
Establishment of registry
127.669
Oregon Health Authority not required to perform certain acts
127.672
POLST not required
127.678
Confidentiality
127.681
Immunity from liability
127.684
Short title
127.700
Definitions for ORS 127.700 to 127.737
127.702
Persons who may make declaration for mental health treatment
127.703
Required policies regarding mental health treatment rights information
127.705
Designation of attorney-in-fact for decisions about mental health treatment
127.707
Execution of declaration
127.710
Operation of declaration
127.712
Scope of authority of attorney-in-fact
127.715
Prohibitions against requiring person to execute or refrain from executing declaration
127.717
Declaration to be made part of medical record
127.720
Circumstances in which physician or provider may disregard declaration
127.722
Revocation of declaration
127.725
Limitations on liability of physician or provider
127.727
Persons prohibited from serving as attorney-in-fact
127.730
Persons prohibited from serving as witnesses to declaration
127.732
Withdrawal of attorney-in-fact
127.736
Form of declaration
127.737
Certain other laws applicable to declaration
127.760
Consent to health care services by person appointed by hospital
127.765
Health care advocate
127.800
§1.01. Definitions
127.805
§2.01. Who may initiate a written request for medication
127.810
§2.02. Form of the written request
127.815
§3.01. Attending physician responsibilities
127.820
§3.02. Consulting physician confirmation
127.825
§3.03. Counseling referral
127.830
§3.04. Informed decision
127.835
§3.05. Family notification
127.840
§3.06. Written and oral requests
127.845
§3.07. Right to rescind request
127.850
§3.08. Waiting periods
127.855
§3.09. Medical record documentation requirements
127.860
§3.10. Residency requirement
127.865
§3.11. Reporting requirements
127.870
§3.12. Effect on construction of wills, contracts and statutes
127.875
§3.13. Insurance or annuity policies
127.880
§3.14. Construction of Act
127.885
§4.01. Immunities
127.890
§4.02. Liabilities
127.892
Claims by governmental entity for costs incurred
127.895
§5.01. Severability
127.897
§6.01. Form of the request
127.995
Penalties
Green check means up to date. Up to date