[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 Health Care Power of Attorney 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.
HCP_AL19
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You should not appoint any of the following persons as your Agent:
(1) your treating physician or health care provider;
(2) an employee of your physician or health care provider unless the person is your relative;
(3) your residential care provider; or
(4) an employee of your residential care provider unless the person is your relative.
HCP_AL01
HAL01010
Name: |City: |State: |[Include country]Country: |
HCP_AL01
HWho is this Durable Power of Attorney for Health Care being created for?
Enter the Agent's name or use the P.I. Manager to select and paste a record. The Agent will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
HAL01022
Relation:#|
HCP_AL01
;What is the Agent's relationship, if any, to the Principal?
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County: |[Include SSN]SSN: |
HCP_AL16
;What are the Principal's county and social security number?
Enter the Principal's county or parish or edit the information as desired.
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HCP_AL18
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Limitations:#|
HCP_AL07
nWhat limitations, if any, will there be on the Agent's authority to make decisions on behalf of the Principal?
If desired, specify any limitations on the Agent's authority. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
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IAL07255
Yes, the Agent will have access to information regarding the Principal's health.
HCP_AL08
>Will the Agent have access to the Principal's medical records?
Enter an X if the Agent will have the authority (subject to any stated limitations) to: (a) request, review and receive any information regarding the Principal's physical or mental health, including, but not limited to, medical and hospital records; and (b) consent to the disclosure of this information to others.
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Yes. The Agent may execute: (a) documents to authorize my admission to or discharge from any health care facility; (b) documents consenting to or refusing treatment; and (c) any waiver or liability release required by a hospital or physician.
HCP_AL09
NWill the Agent have the power to sign health care documents for the Principal?
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WITNESS STATEMENT: I declare that the Principal has identified himself or herself to me, that the Principal signed or acknowledged this document in my presence, appears to be of sound mind, and under no duress, fraud or undue influence. I am not the person appointed as Agent or Alternate Agent by this document, nor am I a provider of health or residential care, an employee of a provider of health or residential care, the operator of a community care facility, or an employee of an operator of a health care facility. I further declare that I am not related to the Principal by blood, marriage, or adoption, and to the best of my knowledge, I am not a creditor of the Principal or entitled to any part of the estate of the Principal under a will now existing or by operation of law.
HCP_AL17
IAL18002
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_AL17
2What are the names and addresses of the witnesses?
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IAL18002
HCP_AL03
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Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
HCP_AL04
MWhat are your desires concerning life-sustaining treatment and/or procedures?
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining procedures.
IGN04006
IGN04011
IGN04022
If I have an incurable conditionIf I am permanently unconsciousEither of the above
HCP_AL04
aUnder what circumstances should life-sustaining treatment or procedures be withheld or withdrawn?
Enter an X to withhold life-sustaining procedures if the condition of the Principal is incurable or irreversible and is expected to result in death within a relatively short time without such procedures.
Enter an X to withhold life-sustaining procedures if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-sustaining procedures if the Principal's condition is incurable and is expected to result in death within a relatively short time (without such procedures) or if the Principal is in a permanently unconscious state.
IGN04022
Specific desires:#|
HCP_AL04
VWhat are your specific desires concerning life-sustaining treatment and/or procedures?
IGN04022
Yes, include nutrition and fluids paragraph.
HCP_AL04
LDo you wish to state your desires regarding artificial nutrition and fluids?
IGN04023
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YesNo
HCP_AL04
Will artificially administered nutrition and fluids be included in the "life-sustaining procedures" that may be withheld or withdrawn?
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Yes, include life-sustaining procedures section.
HCP_AL04
GDo you wish to state your desires regarding life-sustaining procedures?
IGN04003
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Special provisions:#|
HCP_AL05
IWhat special provisions, if any, do you wish to include in this document?
If desired, enter any special health care provisions that you would like to include in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
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IGN06255
Values and preferences:#|
HCP_AL06
DWhat personal values, if any, do you wish to state in this document?
If desired, specify any values and preferences about health care. For example, describe values or religious preferences, or your desires regarding the location of treatment. Press [Ctrl+F1] for more information.
=Who, if anyone, will be designated as Second Alternate Agent?
If desired, enter the Second Alternate Agent's name or use the P.I. Manager to select and paste a record. You do not have to name a second Alternate Agent.
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IGN12027
Yes, include Alternate Agent section.
HCP_AL10
,Do you wish to designate an Alternate Agent?
IGN12003
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Agent (or Alternate)Other person
HCP_AL11
YWho do you nominate to be appointed as Guardian, if one is required by legal proceedings?
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