(1) Subject to subsection (2) of this section, a supported decision-making agreement is valid only if it is in substantially the following form:
SUPPORTED DECISION-MAKING AGREEMENT
Appointment of Supporter
I, ..... (name of supported adult), make this agreement of my own free will.
I agree and designate that:
Name: ..... (name of supporter)
Address: ..... (address of supporter)
Phone Number: ..... (phone number of supporter)
Email Address: ..... (email address of supporter)
is my supporter.
My supporter may help me with making everyday life decisions relating to the following:
(Y/N) Obtaining food, clothing, and shelter.
(Y/N) Taking care of my health.
(Y/N) Managing my financial affairs.
(Y/N) Other matters: ..... (specify).
My supporter is not allowed to make decisions for me. To help me with my decisions, my supporter may:
1. Help me access, collect, or obtain information that is relevant to a decision, including medical, psychological, financial, educational, or treatment records;
2. Help me understand my options so I can make an informed decision; and
3. Help me communicate my decision to appropriate persons.
(Y/N) A release allowing my supporter to see protected health information under the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, is attached.
(Y/N) A release allowing my supporter to see educational records under the Family Educational Rights and Privacy Act of 1974, 20 U.S.C. Sec. 1232g, is attached.
Effective Date of Supported Decision-Making Agreement
This supported decision-making agreement is effective immediately and will continue until ..... (insert date) or until the agreement is terminated by my supporter or me or by operation of law.
Signed this ..... (day) day of ..... (month), ..... (year)
Consent of Supporter
I, ..... (name of supporter), acknowledge my responsibilities and consent to act as a supporter under this agreement.
(Signature of supporter)
(Printed name of supporter)
Supporter
(Signature of supported adult)
(Printed name of supported adult)
Supported Adult
(Signature of witness 1)
(Printed name of witness 1)
Witness 1
(Signature of witness 2)
(Printed name of witness 2)
Witness 2
State of .....
County of .....
This record was acknowledged before me on ..... (date) by ..... (name(s) of individuals).
| . . . . |
| (Signature of notary public) |
(Stamp) | |
| . . . . |
| (Title of office) |
| My commission expires: |
| | . . . . |
| | (Date) |
WARNING: PROTECTION FOR VULNERABLE ADULTS AS DEFINED UNDER CHAPTER
74.34 RCW.
IF A PERSON WHO RECEIVES A COPY OF THIS AGREEMENT OR IS AWARE OF THE EXISTENCE OF THIS AGREEMENT HAS CAUSE TO BELIEVE THAT A VULNERABLE ADULT IS BEING ABUSED, ABANDONED, NEGLECTED (INCLUDING SELF-NEGLECT), OR PERSONALLY OR FINANCIALLY EXPLOITED BY THE SUPPORTER, THE PERSON SHALL REPORT THE ALLEGED ABUSE, ABANDONMENT, NEGLECT, SELF-NEGLECT, OR PERSONAL OR FINANCIAL EXPLOITATION TO THE DEPARTMENT OF SOCIAL AND HEALTH SERVICES BY CALLING THE ABUSE HOTLINE AT 1-800-END-HARM.
(2) A supported decision-making agreement may be in any form not inconsistent with subsection (1) of this section and the other requirements of this chapter.
