67Contact person appointment form

67 Contact person appointment form

67 Contact person appointment form

(1) The appointment of a contact person by the patient must be made in the approved form (the contact person appointment form) and include the following—

(a) the patient’s name, date of birth and contact details,

(b) the name and contact details of the coordinating practitioner for the patient,

(c) the contact person’s name, date of birth and contact details,

(d) a statement that the contact person consents to the appointment,

(e) a statement that the contact person understands the person’s role under this Act, including—

(i) that the contact person agrees to comply with guidelines issued by the Health Secretary under section 181(2)(d), and

(ii) the requirements under section 125 and the penalties for contravening the requirements,

(f) if the patient was assisted by an interpreter when making the appointment, the interpreter’s name, contact details and accreditation details,

(g) the contact person’s signature and the date the form was signed,

(h) the patient’s signature, or the signature of the other person who completes the form on behalf of the patient, and the date the form was signed.

(2) Another person may complete the form on behalf of the patient if—

(a) the patient is unable to complete the contact person appointment form, and

(b) the patient directs the person to complete the contact person appointment form, and

(c) the person is an adult.

(3) The patient or the patient’s contact person must give the contact person appointment form to the patient’s coordinating practitioner.

(4) Within 5 business days after receiving the contact person appointment form, the patient’s coordinating practitioner must give a copy of the form to the Board.

Maximum penalty—100 penalty units.

(5) The patient’s coordinating practitioner must not prescribe a voluntary assisted dying substance for the patient before the contact person appointment form is given to the coordinating practitioner.