POWER OF ATTORNEY ACTIVATION LETTER
Confirmation of incapacity to manage property and finances

[Practice name]
[Address]
[Phone and email]

Date signed: [Date]
To: [The attorney named in the document, or To whom it may concern]

Patient: [Patient's full name]
Date of birth: [Date]
Address: [Home address, or the care facility]

THE POWER OF ATTORNEY
Signed on: [Date the document was signed, as shown on the copy]
Attorney: [Name, and their relationship to the patient]
When it takes effect: [The clause and its words, e.g. clause 4: when my physician confirms in writing that I can no longer manage my financial affairs]
Who must confirm: [What the document says, e.g. 1 physician, 2 physicians, a capacity assessor, or nothing, so the law's default applies]
Copy received from: [Name] on [date]

MY ROLE
[Your profession and role, e.g. family physician to the patient since month and year]
[I am not related to the patient or the attorney by blood or marriage and am not named in the document, or describe any relationship]

MY ASSESSMENT
Date: [Date or dates], [in clinic, at home, in hospital, or in a care facility]
Purpose explained: [That I told the patient this assessment is about managing money, and what my findings could mean for them]
Methods: [Interview with the patient alone; tasks such as reading a statement, paying a sample bill, or making change; cognitive testing and score; record review]
Others who informed it: [Names and roles, e.g. a daughter or the bank, and what each reported, or none]
Other causes looked for: [e.g. delirium, medicines, infection, low mood, hearing or vision loss, and what I found]

FINDINGS ABOUT MONEY
Knowing their finances: [What the patient could and couldn't tell me about income, bills, savings, and debts]
Everyday money tasks: [e.g. paying bills, banking, handling cash, and what has gone wrong]
Weighing a decision: [Whether they could understand the facts of a financial choice and foresee what follows from deciding, or not deciding]
Scams and pressure: [Whether they could recognize a risky request, and any recent losses]
Acting on a decision: [Whether they can carry out a choice and remember making it]

OPINION
[Your opinion in the words the document or the law uses, e.g. In my opinion, patient name is incapable of managing property]
Scope: This opinion is about property and financial decisions only. I did not assess [other decisions, e.g. health care, where to live, or making a will].
Cause, in general terms: [Only if the patient agreed, or the document or the law asks for it; otherwise delete this line]

HOW LONG IT IS LIKELY TO LAST
[Likely to be lasting, or could improve, and why]
I will reassess: [Date, or sooner if the patient's condition changes]

TELLING THE PATIENT
I explained my findings to [patient name] on [date], and told them this letter may let the attorney act for them on financial matters.
Their response: [What they said]

[Your name, credentials]
[License or registration number]
[Signature]
Verification: [Practice phone]