This required section states the basic purpose for this document. It is important for the Principal to understand the rights and duties of all parties before executing this document. Press [Ctrl+F1] for more information.
This required section states the name and address of the person appointed to make health care decisions if the Principal is unable to do so. There are limits on who may be the Agent. Press [Ctrl+F1] for more information.
This required section creates a Power of Attorney for Health Care. It shall be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more information.
This is a required section concerning the authority the Agent is given. The Principal grants full power to the Agent to make health care decisions if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This optional section states the Principal'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 Principal the opportunity to include special provisions concerning health care which are not otherwise contained in the document. Press [Ctrl+F1] for more information.
In this optional section the Principal 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 Principal to establish specific limitations upon the decision making authority of the Agent. Press [Ctrl+F1] for more information.
This is an optional section which 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.
This required section states that any prior Power of Attorney for Health Care made by the Principal 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 Principal's desires. Press [Ctrl+F1] for more information.
By signing this required section, the Principal 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_DC
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 "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record.
HDC01
! Disclosure Statement Section (1 of 16)
INFORMATION ABOUT THIS DOCUMENT
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, IT IS VITAL FOR YOU TO KNOW AND UNDERSTAND THESE FACTS:
THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR ATTORNEY-IN-FACT THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU CANNOT MAKE THE DECISIONS FOR YOURSELF.
AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE HEALTH CARE DECISIONS FOR YOURSELF IF YOU ARE MENTALLY COMPETENT TO DO SO. IN ADDITION, AFTER YOU HAVE SIGNED THIS DOCUMENT, NO TREATMENT MAY BE GIVEN TO YOU OR STOPPED OVER YOUR OBJECTION IF YOU ARE MENTALLY COMPETENT TO MAKE THAT DECISION.
YOU MAY STATE IN THIS DOCUMENT ANY TYPE OF TREATMENT THAT YOU DO NOT DESIRE AND ANY THAT YOU WANT TO MAKE SURE YOU RECEIVE.
YOU HAVE THE RIGHT TO TAKE AWAY THE AUTHORITY OF YOUR ATTORNEY-IN-FACT UNLESS YOU HAVE BEEN ADJUDICATED INCOMPETENT, BY NOTIFYING YOUR ATTORNEY-IN-FACT OR HEALTH CARE PROVIDER EITHER ORALLY OR IN WRITING. SHOULD YOU REVOKE THE AUTHORITY OF YOUR ATTORNEY-IN-FACT, IT IS ADVISABLE TO REVOKE IN WRITING AND TO PLACE COPIES OF THE REVOCATION WHEREVER THIS DOCUMENT IS LOCATED.
IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A SOCIAL WORKER, LAWYER, OR OTHER PERSON TO EXPLAIN IT TO YOU.
YOU SHOULD KEEP A COPY OF THIS DOCUMENT AFTER YOU HAVE SIGNED IT.
GIVE A COPY TO THE PERSON YOU NAME AS YOUR ATTORNEY-IN-FACT. IF YOU ARE IN A HEALTH CARE FACILITY, A COPY OF THIS DOCUMENT SHOULD BE INCLUDED IN YOUR MEDICAL RECORD.
This required section explains the purpose of this document and the rights and obligations of the person making the document (the "Principal") and the person appointed to make health care decisions (the "Attorney-in-Fact").
HDC02
! Designation of Health Care Agent Section (2 of 16)
POWER OF ATTORNEY FOR HEALTH CARE
!. DESIGNATION OF AGENT.
I, !, of the District of Columbia, hereby appoint (Your health care provider may not be named as the Attorney-in-Fact.)
Attorney-in-Fact: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
as my Attorney-in-Fact (Agent) to make health care decisions for me if I become unable to make my own health care decisions. This gives my Attorney-in-Fact the power to grant, refuse, or withdraw consent on my behalf for any health care service, treatment or procedure. My Attorney-in-Fact also has the authority to talk to health care personnel, get information and sign forms necessary to carry out these decisions.
This required designation section states the name and address of the person appointed as Health Care Attorney-in-Fact. The Attorney-in-Fact will make health care decisions for the Principal if the Principal 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 "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Attorney-in-Fact's name or use the P.I. Manager to select and paste a record. The Attorney-in-Fact will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
Enter the Attorney-in-Fact's street address or edit the information as desired.
Enter the Attorney-in-Fact's extended street address or edit the information as desired.
Enter the Attorney-in-Fact's city or edit the information as desired.
Enter the Attorney-in-Fact's state/province or edit the information as desired. When naming an Attorney-in-Fact, consider the availability of the Attorney-in-Fact to confer with health care providers and access medical records and information.
Enter the Attorney-in-Fact's zip/postal code or edit the information as desired.
Enter an X to include the Attorney-in-Fact's country. If the Attorney-in-Fact 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 Attorney-in-Fact may be reached during non-business hours.
Enter a phone number at which the Attorney-in-Fact may be reached during business hours, if different from the home phone number.
Enter the relationship of the Attorney-in-Fact to the Principal.
HDC03
! Creation of Power of Attorney for Health Care Section (3 of 16)
!. CREATION OF POWER OF ATTORNEY FOR HEALTH CARE. With this document, I intend to create a Power of Attorney for Health Care, which shall take effect if I become incapable of making my own health care decisions and shall continue during that incapacity.
This required section states that a Power of Attorney for Health Care is being created. It shall only be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more information.
HDC04
! Authority of Agent Section (4 of 16)
!. RIGHTS AND DUTIES OF ATTORNEY-IN-FACT. Subject to any express limitations in this document, my Attorney-in-Fact shall have all the rights, powers and authority related to health care decisions that I would have under District and federal law. This authority shall include, at a minimum:
(a) The authority to grant, refuse or withdraw consent to the provision of any health care service, treatment or procedure;
(b) The right to review my health care records;
(c) The right to be provided with all information necessary to make informed health care decisions;
(d) The authority to select and discharge health care professionals; and
(e) The authority to make decisions regarding admission to or discharge from health care facilities and to take any lawful actions that may be necessary to carry out these decisions.
My Attorney-in-Fact shall make health care decisions as I direct below or as I make known to my Attorney-in-Fact in some other way.
This required section states the general duties and powers of the Attorney-in-Fact on behalf of the Principal. The health care decisions must be consistent with the desires of the Principal as stated in this document, or otherwise known to the Attorney-in-Fact. Press [Ctrl+F1] for more information.
IGN04
! Optional Life-Sustaining Procedures Section (5 of 16)
!. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING CARE, TREATMENT, SERVICES AND PROCEDURES. [Choose 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 procedures 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 procedures.
! I do not want my life to be prolonged and I do not want life-sustaining procedures, except to the extent deemed necessary to provide me with comfort care,
! if I have a condition that is incurable or irreversible and, without the administration of life-sustaining procedures, 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 procedures, 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 procedures]
! [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 procedures" that may be withheld or withdrawn under the conditions given above.
Enter an X to include a section concerning the Principal's wishes regarding life-sustaining procedures. 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 Principal. A living will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures be withdrawn or withheld under certain conditions.
Enter an X if the Principal gives the Agent the discretion to decide if and when life-sustaining procedures may be withdrawn or withheld. The Agent will decide if the burdens of the treatment outweigh the benefits.
Enter an X if the Principal desires that life-sustaining procedures be given only to the extent of providing the Principal with comfort care.
Enter an X to withhold life-sustaining procedures if the condition of the Principal is incurable or irreversible.
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 or the Principal is in a permanently unconscious condition.
Enter an X if the Principal that desires every possible treatment be taken to prolong life to the greatest extent, regardless of cost or chances for recovery.
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining procedures. Any of the above statements may be edited or additional statements may be composed.
Use this space to describe the Principal's desires concerning life-sustaining treatment and/or procedures.
Enter an X to include a paragraph 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 procedures 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 procedures that may be withheld or withdrawn by the Agent's authorization.
IGN06
! Optional Special Provisions Section (6 of 16)
!. 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 (7 of 16)
!. 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.
HDC08
! Optional Limits on Attorney-In-Fact's Authority Section (8 of 16)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY ATTORNEY-IN-FACT:
Enter an X to include a section that allows the Principal to set limitations on the authority given to the Attorney-in-Fact. For example, the Principal may wish to prohibit the Attorney-in-Fact from authorizing certain procedures. Press [Ctrl+F1] for more information.
Use this space to specify any limitations on the Attorney-in-Fact's authority to make decisions on behalf of the Principal.
IGN12
! Optional Designation of Alternate Agent Section (9 of 16)
!. 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 Principal'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 the Alternate Agent's country. If the Alternate Agent resides in a different country, consider the availability of the Alternate 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 hours.
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.
INE13
! Revocation Section (10 of 16)
!. PRIOR DESIGNATIONS REVOKED. I revoke any prior Power of Attorney for Health Care.
This required revocation section states that any prior Power of Attorney for Health Care made by the Principal is revoked. Press [Ctrl+F1] for more information.
IGN16
! Hold Harmless Section (11 of 16)
!. 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 Principal states that the Agent and anyone who relies upon any representation by the Agent shall not be liable to the Principal or any interests involved with the Principal. Press [Ctrl+F1] for more information.
IGN17
! Severability Section (12 of 16)
!. 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 (13 of 16)
!. 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 Principal's desire that the document be legally recognized either as a legal document or a formal statement of the Principal's wishes and desires regarding health care decisions. Press [Ctrl+F1] for more information.
HDC14
! Signature Section (14 of 16)
[This document must be signed in the presence of two witnesses.]
BY MY SIGNATURE I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT.
I sign my name to this form on the _____ day of _______________, 19___, in the District of Columbia.
________________________________________
Signature
Principal Name: !
Principal Address:City: !
County: ! County
State: !
! Country: !
! SSN: !
This section requires the signature of the Principal 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 Principal's city or edit the information as desired. The name was transferred from a previous section and can be modified only by returning to that section.
Enter the Principal's county or parish or edit the information as desired.
Enter the Principal's state/province or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Principal'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 Principal's social security number or edit the information as desired.
HDC15
! Witness Signature Section (15 of 16)
STATEMENT OF WITNESSES
I declare that the person who signed or acknowledged this document is personally known to me, that the person signed or acknowledged this Power of Attorney for Health Care in my presence, and that the person appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as the Attorney-in-Fact by this document, nor am I the health care provider of the Principal or an employee of the health care provider of the Principal.
(AT LEAST 1 OF THE WITNESSES LISTED ABOVE SHALL ALSO SIGN THE FOLLOWING DECLARATION.)
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 entitled to any part of the estate of the Principal under a currently existing will or by operation of law.
This section requires the signature of two witnesses. By signing this section, the witnesses declare that they were present when the Principal signed this document. Note the limits on who may serve as a witness. 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. Review the limits on who may be a witness. 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 (16 of 16)
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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