MAUNALANI NURSING AND REHABILITATION CENTER
RESIDENT SELF-DETERMINATION IN MEDICAL TREATMENT
(Patient Self-Determination Act "PSDA")
ACKNOWLEDGEMENT
I understand that under a Federal law known as the Patient Self-Determination Act " PSDA", Maunalani Nursing and Rehabilitation Center ("Maunalani") is required to provide me with written information at the time of my admission concerning my rights to make decisions concerning my health care and to make advance health-care directives under Hawaii's Uniform Health-Care Directive Act. These rights include my right to accept or refuse medical or surgical treatment and my right to have a written advance directive such as a durable power of attorney for health care. I also understand that Maunalani is required to provide me with written information (see Resident Manual) about their policies to honor any advances directives that I may have and to honor my health-care decisions.
I acknowledge that on the date indicated I (or my legal guardian acting on my behalf) received the following written information from Maunalani by initialing or placing my mark next to each document listed below:
Initial*

Your Advance Directive for Future Health Care
Initial*

Honoring your Decisions Regarding your Health Care
(a summary of Maunalani's policies regarding advance directives, POLST and FAQs)
Initial*

I acknowledge that on the date indicated, I was provided with information regarding my right to make decisions about my own health care, my right to put those decisions in writing by having a durable power of attorney or other written advance directive, and the way in which Maunalani will comply with my healthcare decisions. I also had the opportunity to ask any questions that I might have about my health-care decisions.
Resident's/Representative's Name*
First Last
Resident's/Representative's Signature*
Date*
MM slash DD slash YYYY
Representative's Relationship to Resident*

MAUNALANI NURSING AND REHABILITATION CENTER

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