!"#$&'()0Who will be appointed as Second Alternate Agent?
GAD02031
Relation:#|
GENADD02
*KWhat is the Second Alternate Agent's relationship to the Declarant, if any?
GAD02035
Yes, include divorce/annulment statement.
GENADD02
Do you wish to revoke the Agent's authority if the Agent is or ever becomes your spouse, and the marriage is annulled or you are divorced?
GAD02036
{NEXT_?}
No, spouse will not serve as Agent.
GENADD02
,AWill your spouse continue to serve as Agent if you are separated?
{NEXT_?}
Yes, a Second Alternate Agent will be appointed.
GENADD02
bWill a Second Alternate Agent be appointed if the Alternate Agent is unwilling or unable to serve?
GAD02025
GAD02035
Yes, an Agent will be appointed.
GENADD02
AWill an Agent be appointed to make health care decisions for you?
GAD02002
{NEXT_?}
Any and all decisionsOnly certain decisions
GENADD03
PWhat authority will the Agent have to make health care decisions on your behalf?
GAD03004
GAD03009
My agent is authorized to:#|
GENADD03
WWhat will be the extent of the Agent's authority to make health care decisions for you?
GAD03009
Yes, Agent must attempt to consult you before making health care decisions.
GENADD03
If you are able to communicate, will the Agent be required to discuss health care decisions with you before making a final decision?
Enter an X to include an optional sentence that requires the Agent to attempt to discuss health care decisions with you before making a final decision. If you are unable to communicate, the Agent may make such decisions for you.
GAD03010
Yes, Agent may consult my family before making health care decisions.
GENADD03
\May the Agent discuss health care decisions with your family before making a final decision?
Enter an X to include an optional sentence that allows the Agent to discuss health care decisions with your family (to the extent that they are available) before making a final decision. The Agent may determine when it is appropriate to discuss such decisions with your family.
GAD03011
Yes, include the provision.
GENADD03
Would you like to specify the Agent's authority to request and review health care information, sign releases, and make health care arrangements?
GAD03012
GAD03023
Yes, the Agent will be authorized.
GENADD03
<Will the Agent be authorized to review your medical records?
GAD03013
Yes, the Agent will be authorized.
GENADD03
lWill the Agent be authorized to execute release forms, verbal or written, to obtain health care information?
GAD03014
Yes, the Agent will be authorized.
GENADD03
rWill the Agent be authorized to make all health care arrangements, including selecting your health care providers?
GAD03015
Yes, the Agent will be authorized.
GENADD03
UWill the Agent be authorized to admit or discharge you from any health care facility?
GAD03016
Yes, the Agent will be authorized.
GENADD03
Will the Agent be authorized to sign any necessary waivers or releases from liability required by a hospital, physician, or other health care provider?
Enter an X to authorize the Agent to sign consent or refusal of consent documents for any proposed health care, including waivers of liability. For example, "Consent to Permit Treatment" or "Refusal to Permit Treatment" documents.
GAD03017
I authorize my Agent to:#|
GENADD03
2What other authority, if any, will the Agent have?
If desired, use this space to state the Agent's authority in other terms.
GAD03023
GAD03017
Yes, the representative will be authorized.
GENADD03
If you live in INDIANA, will the Health Care Representative or Agent be authorized to make decisions regarding the withdrawal or withholding of health care?
Enter an X if you reside in INDIANA and want to authorize the Agent to make decisions regarding the withdrawal or withholding of health care. In Indiana, the Agent will not have this authority unless this box is marked. Later options permit you to specify your desires regarding such decisions.
{NEXT_?}
Yes, state authority.
GENADD03
+Do you wish to state the Agent's authority?
GAD03002
{NEXT_?}
ImmediatelyWhen the Declarant is unable to make decisions
GENADD04
1When will the Agent's authority become effective?
GAD04014
{NEXT_?}
Yes, describe when incapable.
GENADD04
^Do you wish to describe when you will be considered incapable of making health care decisions?
GAD04015
GAD04032
One physicianTwo physiciansA specific physician
GENADD04
aWho will make the determination that you are unable to make or communicate health care decisions?
lWhat is the name and address of the physician who will determine your ability to make health care decisions?
GAD04026
Yes, physician's statement to be attached.
GENADD04
NWill a copy of the physician's written statement be attached to this document?
Enter an X to require that the physician's written statement be attached to this document (stating that the physician has personally examined the Declarant and has found him or her to lack the capacity to make his or her own health care decisions).
GAD04027
Yes, the statement will be included in my medical record.
GENADD04
TWill a copy of the physician's written statement be included in your medical record?
GAD04028
GAD04032
Physician's statement shall be reviewed not less than annually.#| Physician's statement shall be reviewed not less than every 180 days.#| Physician's statement shall be reviewed:
GENADD04
5How often will the physician's statement be reviewed?
GAD04032
Yes, Agent's powers will be suspended.
GENADD04
fWill the Agent's powers be suspended if you regain the ability to make your own health care decisions?
{NEXT_?}
Yes, procedures should be withheld or withdrawn.No, any and all medical treatment is desired.Agent to decide.
GENADD05
fDo you wish to have life-sustaining procedures withheld or withdrawn if you have a terminal condition?
GAD05010
Yes, define the term.
GENADD05
7Would you like to define the term "terminal condition"?
GAD05005
GAD05002
Common definition used by many statesSpecific definition for OHIO[Enter your own definition]
GENADD05
KWhich definition of "terminal condition" will be included in this document?
Enter an X to include the following common definition of terminal condition: "Death from an incurable or irreversible condition is imminent, and even if life sustaining procedures are used, there is no reasonable expectation of recovery".
Enter an X to compose a definition of "terminal condition". You may wish to refer to the "Living Will" or "Health Care Power of Attorney" document for the Declarant's state to see a state-specific definition of "terminal condition".
GAD05008
GAD05002
By "terminal condition", I mean:#|
GENADD05
0What is your definition of "terminal condition"?
Complete the sentence by entering the Declarant's definition of the term "terminal condition".
GAD05002
Yes, direct physician.
GENADD05
Would you like to direct your physician to implement life-sustaining treatment for a "trial period" if you have a "terminal condition"?
{NEXT_?}
Yes, procedures should be withheld or withdrawn.No, any and all medical treatment is desired.Agent to decide.
GENADD06
dDo you wish to have life-sustaining procedures withheld or withdrawn if you are in a permanent coma?
GAD06010
Yes, define the term.
GENADD06
3Would you like to define the term "permanent coma"?
GAD06005
GAD06002
Common definition used by many statesSpecific definition for OHIO[Enter your own definition]
GENADD06
GWhich definition of "permanent coma" will be included in this document?
Enter an X to include the following common definition of permanent coma: "I am not conscious and am not aware of my environment; I show no behavioral response to the environment; I am not able to interact with others; and there is no reasonable expectation of my recovery within a medically appropriate period".
Enter an X to compose a definition of "permanent coma". You may wish to refer to the "Living Will" or "Health Care Power of Attorney" document for the Declarant's state to see a state-specific definition of "permanent coma".
GAD06008
GAD06002
By "permanent coma", I mean:#|
GENADD06
,What is your definition of "permanent coma"?
Complete the sentence by entering the Declarant's definition of the term "permanent coma".
GAD06002
Yes, direct physician.
GENADD06
Would you like to direct your physician to implement life-sustaining treatment for a "trial period" if you are in a "permanent coma"?
{NEXT_?}
Any procedure, treatment, intervention, or other measure that has the primary effect of prolonging my life.#| Forms of medical care that only serve to artificially prolong the dying process and include forms of medical treatment which sustain, restore or supplant vital bodily functions.
GENADD07
SWhich definition of "life sustaining procedures" will be included in this document?
{NEXT_?}
If I have a terminal conditionIf I am in a permanent comaIf I have a terminal condition or am in a permanent coma
GENADD08
ZUnder what circumstances do you NOT want to receive artificial nutrition and/or hydration?
Enter an X if the Declarant does not wish to receive artificially administered nutrition and/or hydration if the Declarant has a "terminal condition" (except to the extent necessary to provide comfort and freedom from pain).
Enter an X if the Declarant does not wish to receive artificially administered nutrition and/or hydration if the Declarant is in a "permanent coma" (except to the extent necessary to provide comfort and freedom from pain).
Enter an X if the Declarant does not wish to receive artificially administered nutrition and/or hydration if the Declarant has a "terminal condition" or is in a "permanent coma" (except to the extent necessary to provide comfort and freedom from pain).
{NEXT_?}
Yes, include the following definition: food and fluids that are provided by artificial means such as a nasogastric tube or tube into the stomach, intestines or veins.
GENADD08
cWould you like to include the following definition of the term "artificial nutrition or hydration"?
GAD08008
Agent to decideYesNo
GENADD08
LDo you wish to receive artificially administered nutrition and/or hydration?
GAD08004
{NEXT_?}
Artificial/mechanical respirationYesNo
GENADD09
<Do you wish to receive artificial or mechanical respiration?
GAD09003
Cardiopulmonary resuscitationYesNo
GENADD09
5Do you wish to receive cardiopulmonary resuscitation?
GAD09004
Blood or blood productsYesNo
GENADD09
/Do you wish to receive blood or blood products?
GAD09005
Surgery or invasive diagnostic proceduresYesNo
GENADD09
MDo you wish to receive any form of surgery or invasive diagnostic procedures?
GAD09006
Kidney dialysisYesNo
GENADD09
'Do you wish to receive kidney dialysis?
GAD09007
AntibioticsYesNo
GENADD09
#Do you wish to receive antibiotics?
GAD09008
ChemotherapyYesNo
GENADD09
$Do you wish to receive chemotherapy?
GAD09009
RadiationYesNo
GENADD09
!Do you wish to receive radiation?
GAD09010
#' $(!%)Yes"&*No
GENADD09
4What other medical procedure do you wish to receive?
Enter the name of the procedure or treatment the Declarant wishes to receive or not to receive. (You may enter up to 4 other medical procedures.)
GAD09018
GAD09010
Yes, consider current circumstances.
GENADD09
+lWill the current circumstances be considered when determining whether procedures or treatments are provided?
Enter an X to include a paragraph containing additional options which consider the circumstances at the time any of the previously listed procedures or treatments are prescribed.
GAD09046
{NEXT_?}
If I have a terminal conditionIf I am in a permanent comaIf I have a terminal condition or am in a permanent coma
GENADD09
./0xUnder what circumstances do you wish not to receive the procedures or treatments marked "YES" in the previous questions?
Enter an X if the Declarant does not wish to receive any procedure marked "YES" if the Declarant has a "terminal condition" (except to the extent necessary to provide comfort and freedom from pain).
Enter an X if the Declarant does not wish to receive any procedure marked "YES" if the Declarant is in a "permanent coma" (except to the extent necessary to provide comfort and freedom from pain).
Enter an X if the Declarant does not wish to receive any procedure marked "YES" if the Declarant has a "terminal condition" or is in a "permanent coma" (except to the extent necessary to provide comfort and freedom from pain).
{NEXT_?}
Agent to determine whether the procedures or treatment should be provided.#| Procedures or treatment should not be provided if Declarant is in a coma or has a terminal condition.
GENADD09
What circumstances should be considered when determining whether the previously listed procedures or treatments should be provided?
Enter an X if the Declarant desires that his/her Agent consider the circumstances at the time any of the previously described procedures are prescribed, and that the Agent determine whether the procedure or treatment should be provided.
Enter an X if the Declarant does not wish to receive the previously described procedures if the Declarant has a terminal condition or is in a permanent coma.
GAD09019
{NEXT_?}
Yes, specify procedures.
GENADD09
_Do you wish to specify certain medical procedures that you want to receive or deny at any time?
GAD09002
{NEXT_?}
Yes, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life sustaining procedures, it is my preference that this document be given effect at that point.
GENADD10
tIf you have been diagnosed as pregnant, do you desire that this Directive be enforced if the fetus will not survive?
GAD10003
Yes, if life sustaining procedures will be physically harmful or unreasonably painful to me, I request that such harm or pain be considered in determining whether this document shall be effective if I am pregnant.
GENADD10
}Should pain or physical harm be considered in determining whether life sustaining procedures should be withheld or withdrawn?
{NEXT_?}
Yes, include pregnancy paragraph.
GENADD10
_Do you wish to change the enforcement of this directive if you have been diagnosed as pregnant?
GAD10002
{NEXT_?}
NoYes
GENADD11
2Do you want to donate your organs upon your death?
GAD11004
{NEXT_?}
YesNo
GENADD11
9Has organ donation been provided for in another document?
GAD11006
{NEXT_?}
Yes, state organ donation desires.
GENADD11
PWould you like to state your desires regarding organ donation in this Directive?
GAD11007
{NEXT_?}
Any needed organs, tissues, or partsSpecific organs, tissues, or parts
GENADD11
Which organs are to be donated?
Enter an X if the Declarant authorizes the donation of only certain organs, tissues, or parts. You will be asked to specify the items which may be donated in the next question.
GAD11009
GAD11012
Only the following:#|
GENADD11
7What specific organs, tissues, or parts may be donated?
GAD11012
Any purpose permitted by lawOnly for specific purposes
GENADD11
.For what purpose are the organs to be donated?
GAD11014
{NEXT_?}
The following purposes:#|
GENADD11
QWhat are the limited purposes for which the previously listed organs may be used?
{NEXT_?}
Yes, include organ donation statement.
GENADD11
;Do you wish to state your desires regarding organ donation?
GAD11002
{NEXT_?}
NoYesAgent to decide
GENADD12
Do you consent to an autopsy?
{NEXT_?}
Yes, specify autopsy wishes.
GENADD12
KDo you wish to specify your wishes regarding the performance of an autopsy?
GAD12002
{NEXT_?}
Additional requests/instructions:#|
GENADD13
VWhat other requests or instructions, if any, do you wish to include in this Directive?
{NEXT_?}
GAD13255
Agent (or Alternate Agent)Other person to be named
8Who, if anyone, will be appointed as Alternate Guardian?
{NEXT_?}
GAD14012
Yes, nominate a Guardian.
GENADD14
#Do you wish to nominate a Guardian?
GAD14002
{NEXT_?}
GENADD15
{NEXT_?}
Yes, interpret wishes broadly.
GENADD16
\Would you like to request that the wishes expressed in this document be interpreted broadly?
GAD16004
Yes, this document is a formal statement.
GENADD16
pIf any provision is not legally enforceable, should this document be taken as a formal statement of your wishes?
GAD16005
Yes, care providers should be morally bound by this document.
GENADD16
oIs it your hope that anyone responsible for your care will regard themselves as morally bound by this document?
{NEXT_?}
Yes, honor this document as my final legal right to refuse medical treatment.
GENADD17
hShould this document be honored as the final expression of your legal right to refuse medical treatment?
GAD17002
Yes, I intend not taking my life directly but only my dying not be prolonged.
GENADD17
Would you like to state that you do not intend any direct taking of your life; but only that your dying not be unreasonably prolonged?
GAD17004
Other statement:#|
GENADD17
YDo you wish to include any other statement regarding the interpretation of this document?
If desired, enter any other statement being made by the Declarant.
GAD17011
GAD17004
County: |[Include SSN]SSN: |[Include date of birth]Birthdate: |
GENADD17
?What is your county, social security number, and date of birth?
{NEXT_?}
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
GENADD18
2What are the names and addresses of the witnesses?
{NEXT_?}
GAD18002
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
GENADD19
2What are the names and addresses of the witnesses?
{NEXT_?}
GAD19002
NotaryWitnesses
GENADD19
/Who will acknowledge the Declarant's signature?
GAD19002
{NEXT_?}
GENADD20
{NEXT_?}
This section provides an Acceptance of Designation which must be signed by the Agent ("Patient Advocate") and any alternate Agent ("Successor Patient Advocate").
GENADD21
{NEXT_?}
GENADD22
{NEXT_?}
[THIS SECTION IS FOR YOUR INFORMATION ONLY. IT WILL NOT BE PRINTED.]
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record. It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate. The Advance Health Care Directive should be reviewed: if the Agent or the Alternate Agent is no longer able to serve; if the Agent is your spouse and you become separated or divorced; or if you wish to revise your desires as stated in the document.
(.txt)