[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_GA20
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This section explains the purpose and consequences of this Durable Power of Attorney for Health Care, as well as the rights and obligations of the person making the document (the "Principal") and the person appointed to make health care decisions for the Principal (the "Agent"). This section 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.
Enter the Agent's name or use the P.I. Manager to select and paste a record. The Agent will be authorized to make health care decisions for you if you are unable to do so. Your health care provider may not act as your Agent if he or she is directly or indirectly involved in your health care decisions under this document.
HGA02020
Relation:#|
HCP_GA02
;What is the Agent's relationship, if any, to the Principal?
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Yes, include the description.
HCP_GA03
SDo you wish to include a description of the general duties and powers of the Agent?
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Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
HCP_GA04
;What are your desires concerning life-sustaining treatment?
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining or death-delaying treatment.
HGA04005
HGA04010
HGA04017
If I have an incurable conditionIf I am permanently unconsciousEither of the above
HCP_GA04
SUnder what circumstances should life-sustaining treatment be withheld or withdrawn?
Enter an X to withhold life-sustaining or death-delaying treatment if the condition of the Principal is incurable or irreversible and is expected to result in death within a relatively short time without such treatment.
Enter an X to withhold life-sustaining or death-delaying treatment if the Principal's condition is incurable and is expected to result in death within a relatively short time (without such treatment) or if the Principal is in a permanently unconscious state.
HGA04017
Specific desires:#|
HCP_GA04
DWhat are your specific desires concerning life-sustaining treatment?
HGA04017
Yes, include nutrition and fluids paragraph.
HCP_GA04
LDo you wish to state your desires regarding artificial nutrition and fluids?
HGA04019
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YesNo
HCP_GA04
Will artificially provided nutrition and fluids be included in the "life-sustaining treatment" that may be withheld or withdrawn?
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Yes, include the section.
HCP_GA04
FDo you wish to state your desires regarding life-sustaining treatment?
HGA04002
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This document shall become effective:#|This document shall terminate:#|
HCP_GA11
fWhen will this Durable Power of Attorney for Health Care become effective, and when will it terminate?
If you do not want this document to take effect immediately upon signing, enter a date or specific event (for example, a court determination of your disability, incapacity, or incompetency), upon which this power of attorney will take effect. If no date or event is specified, the document will take effect on the date of signing.
If you desire that this document terminate prior to your death, enter a date or specific event, upon which this power of attorney will terminate. If no date or event is specified, the document will terminate upon the death of the Principal.
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HCP_GA14
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County: |[Include SSN]SSN: |
HCP_GA18
;What are the Principal's county and social security number?
Enter the Principal's county or parish or edit the information as desired.
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Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_GA19
2What are the names and addresses of the witnesses?
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HGA19002
Limitations:#|
HCP_GA07
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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IAL07255
Yes, the Agent will have access to information regarding the Principal's health.
HCP_GA08
>Will the Agent have access to the Principal'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 Principal'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.
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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_GA09
NWill the Agent have the power to sign health care documents for the Principal?
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Special provisions:#|
HCP_GA05
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_GA06
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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IGN07255
Yes.The Agent#| WILLWILL NOT#be authorized to make anatomical gifts of the Principal's body, authorize an autopsy, and direct the disposition of the Principal's remains.
HCP_GA10
kDo you wish to state whether the Agent may make decisions concerning the treatment of the Principal's body?
Enter an X if the Agent WILL be authorized to make decisions concerning anatomical gifts, an autopsy, and the disposition of remains after the Principal's death.
Enter an X if the Agent WILL NOT be authorized to make decisions concerning anatomical gifts, an autopsy, and the disposition of remains after the Principal's death.
=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.
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IGN12027
Yes, include Alternate Agent section.
HCP_GA12
,Do you wish to designate an Alternate Agent?
IGN12003
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Agent (or Alternate)Other person
HCP_GA13
YWho do you nominate to be appointed as Guardian, if one is required by legal proceedings?