[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_CA16
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This section contains a Disclosure Statement which explains the purpose and consequences of this Durable Power of Attorney for Health Care. The Disclosure Statement will appear on the printed document and must be read and understood by the Principal before he or she signs the Durable Power of Attorney for Health Care. Press [Ctrl+F1] for more information.
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 you if you are unable to do so. The Agent may NOT be your Health Care Professional or Provider (or their employee) attending you on the date you sign this document.
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HCP_CA03
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HCP_CA04
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Statement of desires:#|
HCP_CA05
[What are your desires concerning life-prolonging care, treatment, services, and procedures?
Your Agent must make health care decisions that are consistent with your known desires. Use this space to specify any desires concerning life-prolonging care, treatment, services, or procedures. Press [Ctrl+F1] for more information.
HCA05007
Additional provisions:#|
HCP_CA05
NWhat other special provisions do you wish to state regarding your health care?
Use this space to include any additional desires, special provisions, or limitations relevant to this document. For example, specify any types of treatment desired or not desired. You may also describe values, religious preferences, or the location of treatment. Press [Ctrl+F1] for more information.
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HCP_CA06
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HCP_CA07
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HCP_CA08
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Yes. This Durable Power ofAttorney for Health Care will expire#on |
HCP_CA09
IDo you wish to specify a certain date on which this document will expire?
Enter an X to specify a termination date for the document. This document will exist indefinitely if no ending date is specified. Access Document Information for an explanation regarding the "durability" of this document.
<Who, if anyone, will be appointed 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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HCA10027
A Conservator of the person may be appointed for you if a court decides that one should be appointed. The Conservator is responsible for your physical care, which under some circumstances includes making health care decisions for you. The court will appoint the person you nominate unless that would be contrary to your best interests. You may, but are not required to, nominate as your Conservator the same person you named as your Health Care Agent. You can nominate an individual as your Conservator in the following question. You are not required to nominate a Conservator.
7Who will be nominated as Conservator for the Principal?
Enter the Conservator's name or edit the information as desired. This person may be, but does not have to be, the same person as the Agent. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
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City: |State: |
HCP_CA13
#Where will this document be signed?
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Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_CA14
2What are the names and addresses of the witnesses?
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