[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.
5Who will be appointed as Health Care Proxy ("Agent")?
Enter the name of the person who will act as Health Care Proxy ("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.
HAR01012
Relation:#|
HCP_AR01
;What is the Agent's relationship, if any, to the Declarant?
{NEXT_?}
Name: |
HCP_AR01
(Who is this document being prepared for?
HAR01002
Yes, the Agent will be authorized to make all medical decisions for the Declarant if the Declarant is unable to make such decisions.
HCP_AR02
VWill the Agent have the authority to make all health care decisions for the Declarant?
Enter the Declarant's city or edit the information as desired.
{NEXT_?}
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_AR16
2What are the names and addresses of the witnesses?
{NEXT_?}
HAR16002
Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
HCP_AR03
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.
IAR03005
IAR03010
IAR03017
If I have an incurable conditionIf I am permanently unconsciousEither of the above
HCP_AR03
aUnder what circumstances should life-sustaining treatment or procedures be withheld or withdrawn?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.
IAR03017
HCP_AR03
DWhat are your specific desires concerning life-sustaining treatment?
IAR03017
Yes, include nutrition and fluids paragraph.
HCP_AR03
LDo you wish to state your desires regarding artificial nutrition and fluids?
IAR03019
{NEXT_?}
YesNo
HCP_AR03
Will artificially administered nutrition and fluids be included in the "life-sustaining procedures" that may be withheld or withdrawn?
{NEXT_?}
Yes, include life-sustaining treatment section.
HCP_AR03
FDo you wish to state your desires regarding life-sustaining treatment?
IAR03002
{NEXT_?}
Limitations:#|
HCP_AR06
nWhat limitations, if any, will there be on the Agent's authority to make decisions on behalf of the Declarant?
If desired, specify any limitations on the Agent's authority. For example, the Declarant may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
{NEXT_?}
IAR06255
Yes, the Agent will have access to information regarding the Declarant's health.
HCP_AR07
>Will the Agent have access to the Declarant'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 Declarant'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.
{NEXT_?}
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_AR08
NWill the Agent have the power to sign health care documents for the Declarant?
{NEXT_?}
Special provisions:#|
HCP_AR04
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.
{NEXT_?}
IGN06255
Values and preferences:#|
HCP_AR05
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.
{NEXT_?}
IGN12027
Yes, include Alternate Agent section.
HCP_AR09
,Do you wish to designate an Alternate Agent?
IGN12003
{NEXT_?}
Agent (or Alternate)Other person
HCP_AR10
YWho do you nominate to be appointed as Guardian, if one is required by legal proceedings?
(.txt)