Any adult resident of a community-integrated living arrangement who does not have a legal guardian and has not been adjudicated incompetent may designate another adult of his or her choice to serve as the representative of the resident for the sole purpose of receiving notification from the agency or from the Department concerning any incident or condition regarding the health, safety, or well-being of the resident. The designation shall be made in writing and signed by the resident, the designated representative, and a representative of the agency. The agency shall inform the resident of his or her right to designate another adult as a representative for such purposes. The designation may be revoked in writing by the resident at any time. The agency shall provide a designation of representative form that is substantially the same as the following:
 

I, (insert name), am ……. years old and reside at ……..

 
I have not been adjudicated incompetent and do not have a legal guardian.
 
I hereby delegate (insert name, phone number, and e-mail address of designated representative), an adult who resides at ………., as my representative for the sole purpose of receiving notification of any incident that may affect my health, safety or well-being while a resident at ………., and hereby give my consent to (insert name of agency) to communicate with (insert name of designated representative) about any such incident.
 
I understand that I may revoke this Designation of Representative at any time by notifying (insert name of agency) in writing that I wish to do so.
 
I also understand that by executing this document I am waiving my right to confidentiality, but only to the extent of the authority conveyed in this document.
 
(Insert Name of Resident)
 
…………………
Signature of Resident
 
(Insert Name of Representative)
 
………………………
Signature of Representative
 
(Insert Name of Agency Representative)
 
………………………
Signature of Representative”.