Forms

While we never want to think about the end of life, it's important that everyone plan for it. You should consider what kind of care you would want if you were unable to tell your wishes.

There are legal documents that you can use to give your directions in advance. These documents are advance directives. They include documents such as “living wills” or “power of attorney for health care.”

Mercy Care has policies to help you arrange advance directives so your wishes will be honored. 

You have the right to give instructions about what should be done if you are not able to make medical decisions for yourself. Sometimes people become unable to make health care decisions for themselves because of accidents or serious illness. You have the right to say what you want if this happens to you.

This means that, you can:

  • Fill out a written form to give someone the legal authority to make medical decisions for you if you are unable to make decisions yourself.
  • Give your doctors written instructions about how to handle your medical care if you are unable to make decisions yourself.

To use an advance directive, you need to:

Get the form

If you want to have an advance directive, you can get a form from your lawyer, a social worker or some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare.

Fill it out and sign it

This form is a legal document. You should think about having a lawyer help you with it.

Give copies to appropriate people

Give a copy of the form to your doctor. Give another to the person you name on the form as the one to make decisions for you if you can’t.

You may want to give copies to close friends or family members as well. Be sure to keep a copy at home.

If you know ahead of time that you are going to be hospitalized, take a copy of your advance directive with you to the hospital. If you are admitted to the hospital, the staff will ask you if you have signed an advance directive form and if you have it with you.

Resources and forms

Life Care Planning is an important task for all of us, whether young or old, healthy or facing challenges. The Arizona Attorney General offers the forms, at no cost to you.

You can find the forms and more information on the AG's Life Care Planning page. 

 

 

Friends and family play an important role in the care of someone living with a mental illness. They often have critical information to share with health care professionals. They may be the ones providing care, including transportation to appointments and support after a crisis or hospitalization. The treatment team should encourage input from friends and family. And they should consult with loved ones whenever possible.

If you want us to be able to share information about your health with a person or an agency, you should fill out a Consent to Release Protected Health Information (PHI) form.

You can download the form in ENGLISH  or SPANISH. We will only give out your health information to the people or agencies that you list on your form.

If you have any questions or need help, you can call Mercy Care RBHA at 602-586-1841 or 1-800-564-5465; (TTY/TDD) 711.

Here are some important facts about health care privacy.

  • Federal privacy law requires people who receive physical or mental health services to sign a Release of Information (ROI) form if they want certain people to consult with and receive information from their treatment team. This law is known as the Health Insurance Portability and Accountability Act (HIPAA).
  • Each provider needs a signed ROI form to share health information. (There are some exceptions, listed below).
  • The treatment team should explain why it’s a good idea to sign an ROI form. They should encourage members to sign an ROI so someone close to them will understand the medication they’re receiving, possible side effects and other parts of their treatment plan.
  • Inpatient and outpatient providers in the behavioral health system have ROI forms available for their members to sign.
  • If your loved one wants their treatment team to share health information with you, they must sign an ROI for each provider they see.
  • They must sign a new ROI each time they access crisis services. You can get details and learn about the limitations of the ROI/AUD in the Arizona Health Care Cost Containment System (AHCCCS) Protected Health Information Privacy Notice (Notice of Privacy Practices).  

Even without an ROI, federal and state law allows providers to share certain health information with family members and others involved in their care if:

  • The member verbally agrees to share the information.
  • The member has an opportunity to object to sharing information, but does not. For example, if your loved one allows you to come into an exam room during an appointment, the provider can assume that the member doesn’t object to sharing information during that visit.
  • It’s an emergency, or the member does not have the capacity to make health care decisions, and the provider believes disclosing information is in the member’s best interest.
  • The provider believes the member presents a serious and imminent threat to the health or safety of themselves or others.
  • The provider uses the information to notify a family member of the person’s location, general condition or death.
  • Other laws require the provider to share information. 

Nothing in federal or state law prevents friends or family members from sharing information with the treatment team. Providers are expected and encouraged to accept information from loved ones about members under their care.

You can learn more about when a provider is allows to share their patient's health information in this guide: Communicating with a Patient’s Family, Friends, or Others Involved in the Patient’s Care.