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 act as the Agent. Press [Ctrl+F1] for 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 treatment 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 required section enables the Agent to request, review and disclose information regarding the physical and mental condition of the Principal. Press [Ctrl+F1] for more information.
This required section gives the Agent the authority to sign on behalf of the Principal if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This required section states whether or not the Agent has authority to make anatomical gifts for medical purposes, authorize an autopsy or direct disposition of remains. Press [Ctrl+F1] for more information.
This is a required section which states this document will exist indefinitely unless otherwise specified. 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.
In this optional section, the Principal may designate a person to be his/her guardian if one needs to be appointed. Press [Ctrl+F1] for more information.
This required section states 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 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. 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_IL
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. Press [Ctrl+F1] for more information.
Enter the Principal's city or edit the information as desired.
This is a state-specific document. Enter the Principal's state or edit the information as desired. In most cases, the Principal's state will be Illinois.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
HIL01
! Disclosure Statement Section (1 of 21)
POWER OF ATTORNEY FOR HEALTH CARE
(NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU, INCLUDING POWER TO REQUIRE, CONSENT TO OR WITHDRAW ANY TYPE OF PERSONAL CARE OR MEDICAL TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO ADMIT YOU TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME OR OTHER INSTITUTION. THIS FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS; BUT WHEN POWERS ARE EXERCISED, YOUR AGENT WILL HAVE TO USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS FORM AND KEEP A RECORD OF RECEIPTS, DISBURSEMENTS AND SIGNIFICANT ACTIONS TAKEN AS AGENT. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS THE AGENT IS NOT ACTING PROPERLY. YOU MAY NAME SUCCESSOR AGENTS UNDER THIS FORM BUT NOT CO-AGENTS, AND NO HEALTH CARE PROVIDER MAY BE NAMED. UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER IN THE MANNER PROVIDED BELOW, UNTIL YOU REVOKE THIS POWER OR A COURT ACTING ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME DISABLED. THE POWERS YOU GIVE YOUR AGENT, YOUR RIGHT TO REVOKE THOSE POWERS AND THE PENALTIES FOR VIOLATING THE LAW ARE EXPLAINED MORE FULLY IN SECTIONS 4-5, 4-6, 4-9 AND 4-10(b) OF THE ILLINOIS "POWERS OF ATTORNEY FOR HEALTH CARE LAW". IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.)
It is important that this section be read in order to understand 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 for the Principal (the "Agent").
HIL02
! Designation of Health Care Agent Section (2 of 21)
POWER OF ATTORNEY made this _____ day of _______________, 19___.
!. DESIGNATION OF AGENT.
I, !, of
!, ! !,
! Country: !,
hereby appoint:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
(NOTE: Your attending physician or any other health care provider administering health care to you may not act as your Agent.)
as my Attorney-in-Fact (my "Agent") to act for me and in my name (in any way I could act in person) to make any and all decisions for me concerning my personal care, medical treatment, hospitalization and health care and to require, withhold or withdraw any type of medical treatment or procedure, even though my death may ensue.
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 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. Press [Ctrl+F1] for more information.
Enter the Principal's street address or edit the information as desired.
Enter the Principal's extended street address or edit the information as desired.
Enter the Principal's city or edit the information as desired.
This is a state-specific document. Enter the Principal's state or edit the information as desired. In most cases, the Principal's state will be Illinois.
Enter the Principal's zip/postal code 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 the Agent's name 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 Principal if the Principal 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 the Agent resides in a different country, he/she may not be available to discuss medical decisions with the health care providers.
Enter the Agent's country or edit the information as desired.
Enter a phone number at which the Agent may be reached during non-business hours.
Enter a phone number at which the Agent may be reached during business hours, if different from the home phone number.
Enter the relationship of the Agent to the Principal.
IIL03
! Creation of Power of Attorney for Health Care Section (3 of 21)
!. CREATION OF POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Power of Attorney for Health Care. This power of attorney shall take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency.
This required section states that a Power of Attorney for Health Care is being created. Press [Ctrl+F1] for more information.
IGN03
! Authority of Agent Section (4 of 21)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I grant to my Agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In making any decision, my Agent shall attempt to discuss the proposed decision with me to determine my desires if I am able to communicate in any way.
In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent. If my desires regarding a particular health care decision are not known to my Agent, then my Agent shall make the decision for me based upon what my Agent believes to be in my best interests.
This required section states the general duties and powers of the Agent on behalf of the Principal. The health care decisions made by the Agent must be consistent with the desires of the Principal as stated in this document, or otherwise known to the Agent. Press [Ctrl+F1] for more information.
IAR03
! Optional Life-Sustaining Treatment Section (5 of 21)
!. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING CARE, TREATMENT, SERVICES, AND PROCEDURES. [Select 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 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 life-sustaining treatment.
! I do not want my life to be prolonged and I do not want life-sustaining 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 life-sustaining 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 life-sustaining 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 life-sustaining 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 be
! shall NOT be
among the "life-sustaining treatment" 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 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 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 treatment be withdrawn or withheld under certain conditions.
Enter an X if the Principal does not want any life-sustaining treatment if the burdens of treatment outweigh the benefits.
Enter an X if the Principal desires that life-sustaining treatment be given only to the extent of providing the Principal with comfort.
Enter an X to withhold life-sustaining treatment if the condition of the Principal is incurable or irreversible.
Enter an X to withhold life-sustaining treatment if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-sustaining treatment if the Principal's condition is incurable or if the Principal is in a permanently unconscious state.
Enter an X if the Principal desires that every possible procedure 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 treatment. Any of the above statements may be edited or additional statements may be composed.
Use this space to indicate desires concerning life-sustaining 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 life-sustaining treatment 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 treatment that may be withheld or withdrawn by the Agent's authorization.
IGN06
! Optional Special Provisions Section (6 of 21)
!. 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 21)
!. 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.
IAL07
! Optional Limits on Agent's Authority Section (8 of 21)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT:
Enter an X to include a section that allows the Principal to establish limitations on the authority given to the Agent. For example, the Principal 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 Principal.
HIL09
! Inspection and Disclosure of Information Section (9 of 21)
!. 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.
This required section enables the Agent to request, review, and disclose any information concerning the physical or mental condition of the Principal. Press [Ctrl+F1] for more information.
HIL10
! Signing Documents, Waivers, and Releases Section (10 of 21)
!. 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.
This required section gives the Agent the power to sign health care documents (such as admission, discharge, consent, or release forms) on behalf of the Principal. The Agent is NOT responsible for the cost of any medical service provided to the principal. Press [Ctrl+F1] for more information.
IIL12
! Autopsy, Anatomical Gifts, Disposition of Remains Section (11 of 21)
!. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS.
! I authorize my Agent, to the extent permitted by law,
! I do not authorize my Agent
to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains.
This required section states whether or not the Agent has the authority to make anatomical gifts, authorize an autopsy, and decide upon the disposition of the Principal's remains. Press [Ctrl+F1] for more information.
Enter X if the Agent WILL be authorized to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains, to the extent permitted by law. Press [Ctrl+F1] for more information.
Enter X if the Agent WILL NOT be authorized to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains, to the extent permitted by law.
HIL12
! Duration Section (12 of 21)
!. DURATION. (THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE MANNER PROVIDED IN SECTION 4-6 OF THE ILLINOIS "POWERS OF ATTORNEY FOR HEALTH CARE LAW". ABSENT AMENDMENT OR REVOCATION, THE AUTHORITY GRANTED IN THIS POWER OF ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS POWER IS SIGNED AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF ANATOMICAL GIFT, AUTOPSY OR DISPOSITION OF REMAINS IS AUTHORIZED, UNLESS A LIMITATION ON THE BEGINNING DATE OR DURATION IS MADE IN THIS DOCUMENT.)
This power of attorney shall become effective
(Insert a future date or event during your lifetime, such as a court determination of your disability, when you want this power to first take effect.)
This power of attorney shall terminate
(Insert a future date or event, when you want this power to terminate prior to your death.)
This required section states that this document will exist indefinitely unless a specific date is established. Press [Ctrl+F1] for more information.
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, this document will take effect on the date of signing. Press [Ctrl+F1] for more information.
Enter a date or specific event upon which this power of attorney will terminate. If no date or event is specified, this document will terminate upon the Principal's death.
IGN12
! Optional Designation of Alternate Agent Section (13 of 21)
!. 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 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.
HIL14
! Optional Nomination of Guardian Section (14 of 21)
!. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed, I nominate the following person to serve as such Guardian, to serve without bond or security.
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Enter an X to include a section that allows the Principal to nominate a person to serve as the Principal's Guardian if one is required by legal proceedings. This 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 the Guardian's name or use the P.I. Manager to select and paste a record.
Enter the Guardian's street address or edit the information as desired.
Enter the Guardian's extended street address or edit the information as desired.
Enter the Guardian's city or edit the information as desired. The Guardian will need to be available to act for the Principal.
Enter the Guardian's state/province or edit the pasted information as desired.
Enter the Guardian's zip/postal code or edit the information as desired.
Enter an X to include the Guardian's country. It is very unlikely that a court would appoint a person living in another country as a Guardian for the Principal.
Enter the Guardian's country or edit the information as desired.
INE13
! Revocation Section (15 of 21)
!. 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 (16 of 21)
!. 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 (17 of 21)
!. 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 (18 of 21)
!. 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.
HIL19
! Signature Section (19 of 21)
[This document must be signed in the presence of two witnesses.]
I am fully informed as to all the contents of this form and understand the full import of this grant of powers to my Agent.
Signed on _____ day of _______________, 19___.
________________________________________
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 county or parish 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.
HIL20
! Witness Signature Section (20 of 21)
The Principal has had an opportunity to read the above form and has signed the above form in our presence. We, the undersigned, each being over 18 years of age, witness the Principal's signature at the request and in the presence of the Principal, and in the presence of each other, on the day and year above set out.
YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND SUCCESSOR AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU INCLUDE SPECIMEN SIGNATURES IN THIS POWER OF ATTORNEY, YOU MUST COMPLETE THE CERTIFICATION BELOW THE SIGNATURES OF THE AGENTS.
Specimen signatures of Agent I certify that the signatures of
and successor(s). my Agent and successor(s) are correct.
This document requires the signatures of two witnesses. By signing this section, the witnesses declare that they were present when the Principal signed this document. 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 (21 of 21)
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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