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 Agent. Press [Ctrl+F1] for information.
This required section describes the authority given to the Agent. The Declarant grants full power to the Agent to make health care decisions if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
This optional section states the Declarant's wishes regarding maintenance medical treatments 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 in 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 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 the methods by which the appointment of a Health Care Agent may be 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 optional section states that if the Declarant is admitted to a nursing home or related institution, one witness must be designated as a Patient Advocate or Ombudsman. 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_DE
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 for whom this document is being created (the "Declarant") or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Declarant's city or edit the information as desired.
This is a state-specific document. Enter the Declarant's state or edit the information as desired. In most cases, the Declarant's state will be Delaware.
Enter an X to include the Declarant's country, if outside the United States.
Enter the country or edit the information as desired.
HDE01
! Designation of Health Care Agent Section (1 of 17)
[Delaware does not have a Health Care Power of Attorney statute. However, the Delaware Death with Dignity Act permits the appointment of an Agent to exercise a patient's right to accept or refuse medical treatment which would extend the patient's life. Although the Act does not address all health care decisions for an incapacitated person, the program offers such options. Furthermore, the U.S. Supreme Court has invited individuals to make their wishes known by making advance health care directives.]
DECLARATION REGARDING THE APPOINTMENT OF
HEALTH CARE AGENT
!. DESIGNATION OF HEALTH CARE AGENT.
I, !, of !, !,
! Country: !,
being of sound mind, willfully and voluntarily appoint:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
to be my Health Care Agent, who will act on my behalf if, due to a condition resulting from illness or injury and, in the judgment of my attending physician, I am incapable of making a decision in the exercise of the right to accept or refuse medical treatment.
This required section states the name and address of the person appointed as Health Care 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 for whom this document is being created (the "Declarant") or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Declarant's city or edit the information as desired.
This is a state-specific document. Enter the Declarant's state or edit the information as desired. In most cases, the Declarant's state will be Delaware.
Enter an X to include the Declarant's country, if outside the United States.
Enter the country or edit the information as desired.
Enter the name of the person who will be the Agent or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Agent which appear later in this section. The Agent will have the authority to make health care decisions for the Declarant if the Declarant is unable to do so.
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 an 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 Agent's country, if outside the United States. If the Agent resides in a different country, he/she may not be available to discuss medical decisions with the health care provider.
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.
HDE02
! Authority of Agent Section (2 of 17)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. My Health Care Agent is authorized to accept or refuse medical treatment proposed for me if, in the judgment of the attending physician, I am incapable of making that decision. This authority shall include the right to refuse medical treatment which would extend my life. My Agent has a duty to act in good faith, and with due regard for my benefit and my interests.
This required section states the general duties and powers of the Agent on behalf of the Declarant. The health care decisions made by the Agent must be consistent with the desires of the Declarant as stated in this document, or otherwise known to the Agent. Press [Ctrl+F1] for more information.
HDE03
! Optional Maintenance Medical Treatment Section (3 of 17)
!. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING CARE, TREATMENT, SERVICES AND PROCEDURES: [Choose one of 5 choices; 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 maintenance medical 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 maintenance medical treatment.
! I do not want my life to be prolonged and I do not want maintenance medical treatment, 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 maintenance medical 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 maintenance medical 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 maintenance medical 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 "maintenance medical treatment" that may be withheld or withdrawn under the conditions given above.
Enter an X to include a section which states the Declarant's wishes regarding maintenance medical 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/her intention that medical maintenance treatment be withdrawn or withheld under certain conditions.
Enter an X if the Declarant gives the Agent the discretion to decide if and when medical maintenance treatment may be withdrawn or withheld. The Agent will decide if the burdens of the treatment outweigh the benefits.
Enter an X if the Declarant desires maintenance medical treatment to be given only to the extent of providing the Declarant with comfort care.
Enter an X to withhold maintenance medical treatment if the condition of the Declarant is incurable or irreversible.
Enter an X to withhold maintenance medical treatment if the Declarant is in a permanently unconscious condition.
Enter an X to withhold maintenance medical treatment if the Declarant's condition is incurable or the Declarant is in a permanently unconscious state.
Enter an X if the Declarant desires every possible procedure to 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 maintenance medical 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 maintenance medical 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 maintenance medical treatment that may be withdrawn or withheld by the Agent's authorization.
Enter an X if artificial nutrition and fluids SHALL NOT be among the maintenance medical 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.
HDE10
! Revocation Section (10 of 17)
!. REVOCATION. This declaration may be revoked at any time without regard to your mental state or competency by destroying this document or by making a new declaration. This declaration may also be revoked by an oral statement made in the presence of two (2) witnesses, each 18 years of age or older, of your intention to revoke this declaration.
This required revocation section states that this declaration may be revoked at any time. This revocation becomes effective upon communication to the health care provider by the Declarant or by a witness to the revocation. Press [Ctrl+F1] for more information.
IGN16
! Hold Harmless Section (11 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 (12 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 (13 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.
HDE14
! Signature Section (14 of 17)
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY
IN THE PRESENCE OF TWO WITNESSES)
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: !
County: ! County
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 county/parish or edit the information. The other address information was transferred from a previous section and can be modified only by returning to that section.
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 or edit the information.
HDE15
! Witness Signature Section (15 of 17)
STATEMENT OF WITNESSES
The Declarant signed this Declaration in my presence, and we signed as witnesses in the Declarant's presence and in the presence of each other. I did not sign the Declarant's signature above for or at the direction of the Declarant. I am at least 18 years of age and am not related to the Declarant by blood or marriage, entitled to any portion of the estate of the Declarant under any existing will of the Declarant or by operation of law, or directly financially responsible for Declarant's medical care. I do not have a present or inchoate claim against any portion of the Declarant's estate. I am not an employee of the hospital or health care facility in which the Declarant is a patient.
This section requires the signature of two witnesses. By signing this section, the witnesses declare that they were present when the Declarant signed this document. Note the limits on who may serve as 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.
HDE16
! Optional Patient Advocate/Ombudsman Section (16 of 17)
(If the Declarant is a resident of a sanatorium, rest home, nursing home, boarding home or related institution at the time the Declaration is signed, one witness must be a person designated as a Patient Advocate or Ombudsman by either the Division of Aging or the Public Guardian, and must also have the qualifications required of other witnesses.)
Enter an X to include a section regarding a Patient Advocate or an Ombudsman if the Declarant is a resident of a health care facility (for example, a rest home, nursing home, sanatorium, or related institution). Press [Ctrl+F1] for more information.
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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