DOCUMENT DECISION MAKERS

If you have a Representation Agreement, you already have a decision maker, therefore you do not need to fill out the Temporary Substitute Decision Makers form. You can fill out the form if you wish, as it will make it easier for first responders to contact your family.

If you do not have a Representation Agreement with someone, your health care decision will be made by the people listed on your Temporary Substitute Decision Makers form.

Open the Temporary Substitute Decision Maker Form. Fill out the form in your web browser and then print the form or

Print the blank Temporary Substitute Decision Maker Form and fill out.

The completed form should be stored in your Greensleeve so that it can be accessed by first responders to give them immediate access to names and contact information for people you would like to make decisions on your behalf. The TSDM form is only used if you are not capable of making your own decisions.

How to Complete the Temporary Substitute Decision Maker Form

  • Complete the Personal Identification section at the top of the form. Make sure to include your name and the date you filled out this form.

  • Complete the Temporary Substitute Decision Maker List section of the form. Enter a name and contact number for the following decision makers:

    • Spouse
    • Adult Children
    • Parents
    • Brothers or Sisters
    • Grandparents
    • Grandchildren
    • Anyone else related by birth or adoption
    • Close friend
    • A person immediately related by marriage
  • If there is a person you don't want involved in your health care decisions, make sure to include them in the last section of the form.


Place a copy of your Temporary Substitute Decision Maker form in your greensleeve.