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New Jersey Department of Children and Families Policy Manual




Child Protection and Permanency

Effective Date:






Health Services







Health Care Representative Directive


Health Care Representative Directive Form     9-20-2010


CP&P casework staff encourage adolescents in their caseloads, age 18 or older, to name a Health Care Representative, an adult who will have legal authority to make health care and treatment decisions on the adolescent’s behalf in the event the adolescent becomes incapacitated.


CP&P Form 11-73, Health Care Representative Proxy Directive, is a legal document, completed by adolescents, 18 years of age or older, in care or exiting care, to designate a Health Care Representative.


CP&P Form 11-73 becomes effective once:


•     It is transmitted to the adolescent‘s attending physician or health care institution; and

•     An attending physician and one other doctor confirm, in writing, that the adolescent is unable to make decisions regarding his or her health care.

See CP&P Form 11-73, Health Care Representative Proxy Directive, in the on-line Forms Manual.


Who Can Be Named a Health Care Representative     9-20-2010


Casework staff provide this form to the adolescent, along with a copy of the pamphlet, “Health Care Representative,“ CP&P Form 11-74, which advises the adolescent of the benefits of selecting a Health Care Representative.


In order to support the development of lifelong connections to caring adults, casework staff advise the adolescent that he or she may name a friend, an adult sibling, a parent, or a relative as his or her Health Care Representative. (The adolescent may not name a staff person of CP&P, DCF, or a provider agency as his or her Health Care Representative. Similarly, the adolescent’s health care provider may not be appointed as his or her Health Care Representative.) 


More than one Health Care Representative may be identified, with one being the Primary and one the Secondary (an Alternate Representative), should the Primary be unavailable. 


Key Steps When Completing the Form     9-20-2010


Key elements to discuss with the adolescent regarding CP&P Form 11-73, Health Care Representative Directive, include:


•     Selecting a Health Care Representative is a decision whereby the young adult takes a proactive role in his or her own health care.

•     Selecting a Health Care Representative is a reversible decision.

•     An adolescent may take this opportunity to consider what his or her medical care and health treatment wishes are, should he or she become incapacitated.

•     A Health Care Representative is only consulted by medical staff after two doctors determine that the adolescent is incapacitated.

•     Casework staff advise adolescent to 1) speak to the person(s) he or she wants to designate as Health Care Representative; 2) assure that the person will represent the adolescent‘s health care and treatment wishes; and 3) seek that person’s consent to name him or her as a Health Care Representative for the adolescent before the adolescent signs the Health Care Representative Proxy Directive form.

•     The adolescent‘s primary health care provider and/or CP&P Child Health Unit nurses are available, if the adolescent has additional questions.

Requirements     9-20-2010

An appointment of a Health Care Representative must be:


•     Voluntary, in writing, and dated;

•     Signed by the adolescent; and

•     Signed in the presence of two witnesses or a notary public. Note: CP&P staff may serve as a witness.

The Health Care Representative:


•     Must be at least 18 years old;

•     Makes medical decisions on behalf of the adolescent, should the adolescent become incapacitated;

•     Begins making decisions when two (2) doctors certify, in writing, that the patient (adolescent) is incapacitated, and is no longer able to give consent for his or her own treatment;

•     Has the legal power to accept or refuse medical treatment for the adolescent; has access to all the adolescent’s medical records; and, if death should occur, makes decisions regarding donating organs, authorizing an autopsy, and disposing of the body after death.

The decisions made by the Health Care Representative cannot be overruled by other family members or a doctor without court intervention.


The adolescent may choose a Health Care Representative upon turning 18 years of age. The Health Care Representative must be 18 years old, or older. (See Section 475(8)(B)(iii) of the Social Security Act.)


Health Care Representative Declines Appointment     9-20-2010


The Health Care Representative is required to notify the adolescent, the adolescent‘s legal representative, and any and all of the adolescent’s health care providers, if he or she resigns from the appointment of being the adolescent‘s Health Care Representative should the adolescent become incapacitated.


Adolescent Revokes Appointment     9-20-2010


The adolescent may revoke the appointment of a Health Care Representative by doing all of the following:


•     Destroying the declaration document (CP&P Form 11-73);

•     Notifying the Health Care Representative verbally or in writing; and

•     Verbally or in writing telling his or her doctor that he or she has revoked the appointment. The revocation is not effective until the doctor is notified.

Additional Instructions Provided by the Adolescent     9-20-2010


In addition to choosing a Health Care Representative, the adolescent may also provide instruction and direction, in writing, regarding his or her wishes about his or her medical care in the event that he or she develops a terminal condition or is permanently unconscious and can no longer make his or her own medical decisions.


Relevant NJS Windows and Forms     9-20-2010


•     CP&P Form 5-43, Transitional Plan for Adolescents

•     CP&P Form 5-66, Adolescent Case Closing Agreement

•     CP&P Form 5-67, Adolescent Case Closing Checklist

•     CP&P Form 11-73, Health Care Representative Proxy Directive

•     CP&P Form 11-74, Health Care Representative brochure


Related Policy     9-20-2010


•     CP&P-III-B-5-500, Family Engagement

•     CP&P-III-A-1-500, Services to Adolescents Age 18 to 21

•     CP&P-VI-A-1-101, Independent Living Placement

•     CP&P-VI-B-1-300, Adolescent Services Toward Self-Sufficiency

•     CP&P-V-A-3-500, Medicaid Extension for Young Adults (MEYA), Also Known as Chafee Medicaid