This required section states the name and address of the person appointed to make health care decisions if the Declarant is unable to do so. There are limits on who may act as the Proxy ("Agent"). Press [Ctrl+F1] for more.
This is a optional section concerning the authority the Agent is given. The Declarant grants full power to the Agent to make health care decisions if Declarant is unable to do so. Press [Ctrl+F1] for more information.
This optional section states the Declarant's wishes regarding life-sustaining procedures which artificially postpone death, and desires regarding artificial food and nutrition. Press [Ctrl+F1] for more information.
This optional section gives the Declarant the opportunity to include special provisions concerning health care which are not otherwise contained within the document. Press [Ctrl+F1] for more information.
In this optional section the Declarant may specify any values or preferences, such as religious beliefs, location of care or personal values, which pertain to this document. Press [Ctrl+F1] for more information.
This optional section enables the Declarant to establish specific limitations upon the decision making authority of the Agent. Press [Ctrl+F1] for more information.
This optional section enables the Agent to request, review and disclose information regarding the physical and mental condition of the Declarant. Press [Ctrl+F1] for more information.
This optional section gives the Agent the authority to sign on behalf of the Declarant if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
This optional section states that if the original Agent is not available, an Alternate Agent will assume responsibility of the original Agent. Press [Ctrl+F1] for more information.
In this optional section, the Declarant may designate a person to be his/her Guardian if one needs to be appointed. Press [Ctrl+F1] for more information.
This required section states that any prior Health Care Proxy made by the Declarant is revoked. Press [Ctrl+F1] for more information.
This required section states that any person or entity who faithfully carries out the terms and provisions of this document shall not be held liable for any damages which may occur. Press [Ctrl+F1] for more information.
This required section prevents the entire document from being invalidated if any provision of the document is declared invalid. Press [Ctrl+F1] for more information.
This required section states that this document be legally binding and if it is not recognized as a legal document it will be treated as a formal statement of the Declarant's desires. Press [Ctrl+F1] for more information.
By signing this required section, the Declarant will acknowledge full understanding of the document contents as well as the effects of the granting of powers to the Agent. Press [Ctrl+F1] for more information.
This section requires the signature of two witnesses. The witness statement describes limits on who may act as a witness. Press [Ctrl+F1] for more information.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Press [Ctrl+F1] for more information.
Times New Roman
Health Care POA
HCP_AR
The Health Care Power of Attorney is a document under which a competent adult (a Principal), prior to becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures should be withheld or withdrawn under certain circumstances, and designates a person who will have authority to make health care decisions for the Principal, if the Principal is unable to do so.
Enter the name of the person that this document is being created for (the "Declarant") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
HAR01
! Designation of Health Care Proxy Section (1 of 17)
[Arkansas does not have a Health Care Power of Attorney statute. However, the Arkansas law permits you to appoint an Attorney-in-Fact (Agent) to act for you if you become disabled or incapacitated. Although the act is silent with respect to health care decisions, the U.S. Supreme Court has invited individuals to make their wishes known by making advance health care directives such as a Living Will and a Health Care Power of Attorney.]
HEALTH CARE PROXY
[THIS DOCUMENT IS BEING PREPARED FOR !]
If I should become permanently unconscious, incompetent, or otherwise mentally or physically incapable of communication, I direct my attending physician, pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to follow the instructions of my Agent whom I appoint as my Health Care Proxy ("Agent") to decide whether life-sustaining treatment should be withheld or withdrawn:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
This required section states the name and address of the person appointed as Health Care Proxy ("Agent"). The Agent will make health care decisions for the Declarant if he/she is unable to make such decisions. Press [Ctrl+F1] for more information.
Enter the name of the person that this document is being created for (the "Declarant") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter the name of the person who will be the Agent 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 Declarant if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
Enter the Agent's street address or edit the information as desired.
Enter the Agent's extended street address or edit the information as desired.
Enter the Agent's city or edit the information as desired.
Enter the Agent's state/province or edit the information as desired. When naming a Agent, consider the availability of the Agent to confer with health care providers and access medical records and information.
Enter the Agent's zip/postal code or edit the information as desired.
Enter an X to include the country in which the Agent resides. If the Agent resides in a different country, he/she may not be available to discuss medical decisions with the health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Agent can be reached during non-business hours.
Enter a phone number at which the Agent can be reached during business hours, if different from the home phone number.
Enter the relationship of the Agent to the Declarant, or enter "None".
HAR02
! Optional Authority of Agent Section (2 of 17)
I also authorize my Agent to make any other type of medical decision if I am unable to make the decision for myself.
Enter an X to authorize the Agent to make any health care decisions on behalf of the Declarant if he/she is unable to do so. Press [Ctrl+F1] for more information.
IAR03
! Optional Life-Sustaining Treatment Section (3 of 17)
!. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING CARE, TREATMENT, SERVICES, AND PROCEDURES. [Select one of 5 choices; the last choice allows you to compose your own statement.]
! I specifically direct my Agent to follow any "living will" executed by me.
! I do not want my life to be prolonged nor do I want life-sustaining treatment to be provided or continued if my Agent believes the burdens of the treatment outweigh the expected benefits. I want my Agent to consider the relief of suffering, my personal beliefs, the expense involved and the quality as well as the possible extension of my life in making decisions concerning life-sustaining treatment.
! I do not want my life to be prolonged and I do not want life-sustaining treatment, except to the extent deemed necessary to provide me with comfort care, [select one of the 3 following:]
! if I have a condition that is incurable or irreversible and, without the administration of life-sustaining treatment, expected to result in death within a relatively short time.
! if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! if I have a condition that is incurable or irreversible and, without the administration of life-sustaining treatment, expected to result in death within a relatively short time, or if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! I want my life to be prolonged to the greatest extent possible within the standards of accepted medical practice, without regard to my condition, the chances I have for recovery, or the cost of the procedures.
! [User to compose own statement of desires concerning life-sustaining treatment]
! [Optional Nutrition and Fluids Paragraph]
!. STATEMENT OF DESIRES CONCERNING NUTRITION AND FLUIDS.
Artificially provided nutrition or fluids provided by means of a nasogastric tube or tube into the stomach, intestines, or veins,
! shall
! shall NOT
be among the "life-sustaining treatment" that may be withheld or withdrawn under the conditions given above.
Enter an X to include a section concerning the Declarant's wishes regarding life-sustaining treatment. States may define this term differently, but generally it means procedures which artificially postpone death. Press [Ctrl+F1] for more information.
Enter an X if the Agent is to follow any "Living Will" executed by the Declarant. A living will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his or her intention that life-sustaining treatment be withdrawn or withheld under certain conditions.
Enter an X if the Declarant gives the Agent the discretion to decide if and when life-sustaining treatment may be withdrawn or withheld. The Agent will decide if the burdens of treatment outweigh the benefits. Press [Ctrl+F1] for more information.
Enter an X if the Declarant desires that life-sustaining procedures be given only to the extent of providing the Declarant with comfort care.
Enter an X to withhold life-sustaining treatment if the condition of the Declarant is incurable or irreversible.
Enter an X to withhold life-sustaining treatment if the Declarant is in a permanently unconscious condition.
Enter an X to withhold life-sustaining treatment if the Declarant's condition is incurable or if the Declarant is in a permanently unconscious state.
Enter an X if the Declarant desires that every possible procedure be taken to prolong life to the greatest extent regardless of cost or chances for recovery.
Enter an X if the Declarant desires to compose a separate statement of desires concerning life-sustaining treatment. Any of the above statements may be edited or additional statements may be composed.
Use this space to indicate the Declarant's desires concerning life-sustaining treatment.
Enter an X to include a section regarding artificially administered nutrition and fluids. Press [Ctrl+F1] for more information.
Enter an X if artificial nutrition and fluids SHALL be among the life-sustaining treatment that may be withheld or withdrawn by the Agent's authorization.
Enter an X if artificial nutrition and fluids SHALL NOT be among the life-sustaining treatment that may be withheld or withdrawn by the Agent's authorization.
IGN06
! Optional Special Provisions Section (4 of 17)
!. SPECIAL PROVISIONS REGARDING MY HEALTH CARE. (For example, describe your wishes regarding any treatment you desire or do not desire, or admission to a residential care facility.)
Enter an X to include a section regarding special provisions concerning health care which are not otherwise contained in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
Use this space to describe any additional special provisions.
IGN07
! Optional Values and Preferences Section (5 of 17)
!. STATEMENT OF VALUES AND PREFERENCES. (Specify any other wishes, values, religious beliefs, philosophy or other personal values or preferences that are relevant to your instructions. You may also state preferences concerning the location of your care.)
Enter an X to include a section concerning values and preferences about health care. For example, describe values or religious preferences, or the location of treatment. Press [Ctrl+F1] for more information.
Use this space to specify values and preferences.
IAR06
! Optional Limits on Agent's Authority Section (6 of 17)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT:
Enter an X to include a section that allows the Declarant to establish limitations on the authority given to the Agent. For example, the Declarant may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
Use this space to specify any limits on the Agent's authority to make decisions on behalf of the Declarant.
IAR07
! Optional Inspection and Disclosure Section (7 of 17)
!. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my Agent has the power and authority to:
a. Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records;
b. Consent to the disclosure of this information to others.
Enter an X to include a provision which enables the Agent to request, review, and disclose any information regarding the physical or mental condition of the Declarant. Press [Ctrl+F1] for more information.
IAR08
! Optional Signing Documents, Waivers, and Releases Section (8 of 17)
!. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to implement the health care decisions that my Agent is authorized by this document to make, my Health Care Agent has the power and authority to execute on my behalf any of the following:
a. Documents to authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care or assisted living or similar facility or service;
b. Documents titled or purporting to be "Consent to Permit Treatment" or "Refusal to Permit Treatment"; or
c. Any necessary waiver or release from liability required by a hospital or physician.
Enter an X to include a section which gives the Agent the power to sign health care documents (such as admission, discharge, consent, or release forms) on behalf of the Declarant. The Agent is NOT responsible for the cost of any medical service provided to the Declarant. Press [Ctrl+F1] for more information.
IGN12
! Optional Designation of Alternate Agent Section (9 of 17)
!. DESIGNATION OF ALTERNATE AGENT. If the person designated as my Agent is not available or unable to act, I designate the following persons to serve as my Agent to make health care decisions for me as authorized by this document, who serve in the following order:
FIRST ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
SECOND ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Enter an X to designate an Alternate Agent. If the original Agent resigns or is unable to perform, an Alternate Agent will assume all responsibilities of the original Agent. Generally, the designation of the Declarant's spouse as the Agent is revoked upon divorce. Press [Ctrl+F1] for more information.
Enter the Alternate Agent's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Agent's street address or edit the information as desired.
Enter the Alternate Agent's extended street address or edit the information as desired.
Enter the Alternate Agent's city or edit the information as desired.
Enter the Alternate Agent's state/province or edit the information as desired. When naming an Alternate Agent, consider the availability of the Alternate Agent to confer with health care providers.
Enter the Alternate Agent's zip/postal code or edit the information as desired.
Enter an X to include Alternate Agent's country. If the Alternate Agent resides in a different country, consider the availability of the Agent to discuss medical records or information with health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Alternate Agent may be reached during non-business.
Enter a phone number at which the Alternate Agent may be reached during business hours, if different from the home phone number.
Enter an X to include the name of a second Alternate Agent. You do not have to name a second Alternate Agent.
IGN13
! Optional Nomination of Guardian Section (10 of 17)
!. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
! my Agent (or Alternate Agent)
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
to serve as my Guardian.
Enter an X to include a section that allows the Declarant to nominate a person to serve as the Declarant's Guardian if one is required by legal proceedings. This person will be appointed if the Court finds that such appointment is in the Declarant's best interests. Press [Ctrl+F1] for more information.
Enter an X if the nominated Guardian should be the same person as the appointed Agent or Alternate Agent.
Enter an X if the nominated Guardian will be a person other than the Agent or Alternate Agent.
Enter the Guardian's name or use the P.I. Manager to select and paste a record.
Enter the Guardian's street address or edit the information as desired.
Enter the Guardian's extended street address or edit the information as desired.
Enter the Guardian's city or edit the information as desired. The Guardian will need to be available to act for the Declarant.
Enter the Guardian's state/province or edit the information as desired.
Enter the Guardian's zip/postal code or edit the information as desired.
Enter an X to include the Guardian's country, if outside the United States. It is very unlikely that a court would appoint a person living in another country as a Guardian for the Declarant.
Enter the country or edit the information as desired.
HAR11
! Revocation Section (11 of 17)
!. REVOCATION. This declaration may be revoked at any time and in any manner by the Declarant, without regard to the Declarant's mental or physical condition. A revocation is effective upon communication to the attending physician or other health care provider by the Declarant or a witness to the revocation.
This required revocation section describes the manner in which a Health Care Proxy may be revoked. Press [Ctrl+F1] for more information.
IGN16
! Hold Harmless Section (12 of 17)
!. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
This is a required section in which the Declarant states that the Agent and anyone who relies upon any representation by the Agent shall not be liable to the Declarant or any interests involved with the Declarant. Press [Ctrl+F1] for more information.
IGN17
! Severability Section (13 of 17)
!. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
This required section prevents the entire document from being invalidated if any provision of the document is declared invalid. Press [Ctrl+F1] for more information.
IGN18
! Statement of Intentions Section (14 of 17)
!. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
This required section is a statement of the Declarant's desire that the document be legally recognized either as a legal document or a formal statement of the Declarant's wishes and desires regarding health care decisions. Press [Ctrl+F1] for more information.
HAR15
! Signature Section (15 of 17)
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration.
Signed on _____ day of _______________, 19___.
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
State: !
! Country: !
! SSN: !
This section requires the signature of the Declarant in the presence of two witnesses. If this procedure is not followed, the document may be invalid. Press [Ctrl+F1] for more information.
Enter the Declarant's city or edit the information as desired. The name of the Declarant was transferred from an earlier section and can be modified only by returning to that section.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the name of the country in the printed document.
Enter the name of the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By including the social security number, a health care facility is able to file advance health care directives for future reference. Press [Ctrl+F1] for more information on the Patient Self Determination Act.
Enter the Declarant's social security number.
HAR16
! Witness Signature Section (16 of 17)
The Declarant voluntarily signed this writing in my presence.
This document requires the signatures of two witnesses. By signing this section, the witnesses declare that they were present when the Declarant signed this document. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
DOM01
! Health Care Document Information Section (17 of 17)
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.
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;
- if you wish to revise your desires as stated in the document.
It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Generally, the Agent, family, and health care provider are given a copy. This section will not print as part of the document. Press [Ctrl+F1] for more information.
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