It is the responsibility of each intermediate care facility (ICF/IID) community program provider to submit the required forms and supporting documentation to the Surrogate Decision-making Program (SDMP) when a person they serve lacks the capacity to make certain treatment decisions for himself or herself and have no legal guardian or surrogate decision maker.
Forms
- Form 2700, Application for a Treatment Decision by a Surrogate Consent committee
- Form 2705, Certification of Need for Major Medical Treatment
- Form 2710, Certification of Need for Major Dental Treatment
- Form 2715, Certification of Need for Psychoactive Medication Treatment
- Form 2720, Certification of Need for Highly Restrictive Procedure
- Form 2725, List of Persons to Receive Notification
- Form 2726, Notification of a Surrogate Consent Committee Hearing
- Form 2727, Waiver of Designation as Surrogate Decision Maker
- Form 2749, Submitting an Application Packet for a Treatment Decision
- Form 2750, Surrogate Decision Making Program Data Form
Learn About the SDMP
The law and rule pertaining to the SDMP is found in: