[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.
Enter the name of the person who will act as Agent or use the P.I. Manager to select and paste a record. 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.
HIN01028
Relation:#|
HCP_IN01
;What is the Agent's relationship, if any, to the Principal?
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Yes, a Living Will Declaration will be attached.
HCP_IN04
:Will you be attaching a copy of a Living Will Declaration?
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YesNo
HCP_IN05
sWill artificially provided nutrition and fluids be included in the "health care" that may be withheld or withdrawn?
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Yes, include nutrition/fluids section.
HCP_IN05
[Do you wish to state your desires regarding artificially administered nutrition and fluids?
This document authorizes the Agent to make decisions regarding the withdrawal or withholding of health care from the Principal. Enter an X if you want to specify whether the Agent may withhold or withdraw artificial nutrition and hydration. Press [Ctrl+F1] for more information.
STATEMENT OF WITNESSES: The Principal has been personally known to me, and I believe (him/her) to be of sound mind. I did not sign the Principal's signature for, or at the direction of, the Principal. I am not a parent, spouse, or child of the Principal. I am not entitled to any part of the Principal's estate or directly financially responsible for the Principal's medical care. I am competent and at least eighteen (18) years old.
HCP_IN20
HIN20002
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_IN20
2What are the names and addresses of the witnesses?
{NEXT_?}
HIN20002
HCP_IN21
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NOTICE TO ATTORNEY-IN-FACT: The Attorney-in-Fact (the Agent) shall ascertain whether the Principal has notified the Principal's health care providers that a power of attorney has been executed. If the Principal has not notified the Principal's health care providers of the existence of a power of attorney, the Attorney-in-Fact shall notify the health care providers of the existence of the power of attorney.
HCP_IN23
{NEXT_?}
Limitations:#|
HCP_IN08
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.
{NEXT_?}
IAL07255
Yes, the Agent will have access to information regarding the Principal's health.
HCP_IN09
>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_IN10
NWill the Agent have the power to sign health care documents for the Principal?
{NEXT_?}
HCP_IN03
{NEXT_?}
Special provisions:#|
HCP_IN06
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.
{NEXT_?}
IGN06255
Values and preferences:#|
HCP_IN07
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_IN11
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.
{NEXT_?}
IGN12027
Yes, include Alternate Agent section.
HCP_IN13
,Do you wish to designate an Alternate Agent?
IGN12003
{NEXT_?}
Agent (or Alternate)Other person
HCP_IN14
YWho do you nominate to be appointed as Guardian, if one is required by legal proceedings?
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