[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_CT13
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This section contains a Disclosure Statement which explains the purpose and consequences of this 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 Power of Attorney for Health Care. Press [Ctrl+F1] for more information.
HCP_CT01
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The life support systems which I want to have withheld or withdrawn include, but are not limited to, artificial respiration, cardiopulmonary resuscitation, and artificial means of providing nutrition and hydration.
I do want sufficient pain medication to maintain my physical comfort. I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.
HCP_CT02
HCT02005
Name: |
HCP_CT02
'Who is this document being created for?
HCT02004
Yes, life support systems should be withheld or withdrawn.
HCP_CT02
uIf your condition is terminal or you are permanently unconscious, do you wish to have life support systems withdrawn?
HCT02000
Additional life support statement:#|
HCP_CT02
WWhat other desires concerning life support systems should be included in this document?
If desired, use this space to compose your own statement of desires concerning life support systems.
HCT02013
HCT02005
Yes. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
HCP_CT02
SDo you wish to state that this document shall not be effective if you are pregnant?
HCT02014
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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.
HCP_CT02
sIf you have been diagnosed as pregnant, do you desire that this document be enforced if the fetus will not survive?
HCT02015
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.
HCP_CT02
Do you request that pain or physical harm to you be considered in determining whether life sustaining procedures or treatment should be withheld or withdrawn?
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The following persons should not be appointed as a health care agent or alternate health care agent:
(1) your attending physician; (2) an operator, administrator, or employee of a hospital, rest home with nursing supervision, or chronic and convalescent nursing home, if the Principal at the time of the appointment, is a patient or a resident of, or has applied for admission to one of these facilities; or (3) an administrator or employee of a government agency which is financially responsible for the Principal's medical care. Restrictions 2 & 3 do not apply if such person is Principal's relative by blood, marriage or adoption.
!"$%&'<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.
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 Principal if the Principal is unable to do so.
HCT03044
Relation:#|
HCP_CT03
;What is the Agent's relationship, if any, to the Principal?
HCT03002
Limitations:#|
HCP_CT06
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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HCT06255
NoYes
HCP_CT07
DDo you wish to make anatomical gifts of your organs upon your death?
HCT07014
HCT07004
Any needed organs or partsSpecific organs or parts
HCP_CT07
Which organs are to be donated?
Enter an X if the Principal authorizes the donation of only certain organs or parts. You will be asked to name the specific organs in the next question.
HCT07006
HCT07009
Only the following organs or parts::#|
HCP_CT07
.Which specific organs or parts may be donated?
HCT07009
Any purpose permitted by lawOnly for specific purposes
HCP_CT07
.For what purpose are the organs to be donated?
HCT07011
HCT07014
Purpose of organ donation:#|
HCP_CT07
VWhat is the specific purpose for which the previously listed organs are to be donated?
HCT07014
Yes, include autopsy statement.
HCP_CT07
7Do you wish to state your desires regarding an autopsy?
HCT07015
HCT07017
Yes, to the extent permitted by law.No, the Agent is not authorized.
HCP_CT07
1Is the Agent authorized to consent to an autopsy?
HCT07017
Yes, the Agent is authorized.
HCP_CT07
BIs the Agent authorized to direct the disposition of your remains?
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Agent (or Alternate Agent)Other person to be named
HCP_CT08
%Who will be appointed as Conservator?
Enter an X if the nominated Conservator should be the same person as the appointed Agent or Alternate Agent. The person will be appointed if the Court finds that such appointment is in the Principal's best interests. Press [Ctrl+F1] for more information.
Enter an X if the nominated Conservator will be a person other than the Agent or Alternate Agent. The person will be appointed if the Court finds that such appointment is in the Principal's best interests. Press [Ctrl+F1] for more information.
;Who, if anyone, will be appointed as Alternate Conservator?
If desired, enter the Alternate Conservator's name or use the P.I. Manager to select and paste a record. You do not have to name an Alternate Conservator.
EWhat are the Principal's county, country, and social security number?
Enter the Principal's county or edit the information as desired.
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Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_CT12
2What are the names and addresses of the witnesses?
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HCT12005
Special provisions:#|
HCP_CT04
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_CT05
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.
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