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1. Specific Treatment Restrictions: Any limitations or specific exclusions to the permission granted

2. Alternative Decision Maker: Designation of alternative person to make decisions if primary grantor becomes unavailable

3. Religious or Cultural Preferences: Any specific religious or cultural considerations that should be taken into account

4. Cost Authorization: Specific details about financial responsibility and payment authorization

5. Translation Declaration: If the letter is bilingual or has been translated, a statement confirming accuracy of translation

1. Medical History Form: Detailed medical history of the patient including allergies, current medications, and pre-existing conditions

2. Specific Procedure Details: Detailed information about specific procedures being authorized

3. Insurance Information: Copies of insurance cards and coverage details

4. Legal Authority Documentation: Copies of relevant legal documents proving authority to grant permission (e.g., guardianship papers)

5. Physician's Statement: Statement from physician confirming patient's condition and recommended treatment plan