[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_MA18
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This section explains the purpose of this document, as well as the rights and obligations of the person making the document (the "Principal") and the rights and obligations of the person appointed to make health care decisions for the Principal (the "Agent"). This section will appear on the printed document and should be read by the Principal and Agent before the document is signed.
HCP_MA01
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Generally you should not appoint any of the following persons as your Agent:
(1) your treating physician or health care provider; (2) an employee of your physician or health care provider unless the person is your relative; (3) your residential care provider; or (4) an employee of your residential care provider unless the person is your relative.
Enter the Agent's name or use the P.I. Manager to select and paste a record. Note the restrictions on who may serve as Agent that appear in the previous question. The Agent will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
HMA02017
Relation:#|
HCP_MA02
;What is the Agent's relationship, if any, to the Principal?
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HCP_MA03
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HCP_MA09
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HCP_MA10
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County: |[Include SSN]SSN: |
HCP_MA16
;What are the Principal's county and social security number?
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Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_MA17
2What are the names and addresses of the witnesses?
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HMA17002
Limitations:#|
HCP_MA08
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
HCP_MA04
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Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
HCP_MA05
MWhat are your desires concerning life-sustaining treatment and/or procedures?
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining procedures.
IGN04006
IGN04011
IGN04022
If I have an incurable conditionIf I am permanently unconsciousEither of the above
HCP_MA05
aUnder what circumstances should life-sustaining treatment or procedures be withheld or withdrawn?
Enter an X to withhold life-sustaining procedures if the condition of the Principal is incurable or irreversible and is expected to result in death within a relatively short time without such procedures.
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 and is expected to result in death within a relatively short time (without such procedures) or if the Principal is in a permanently unconscious state.
IGN04022
Specific desires:#|
HCP_MA05
VWhat are your specific desires concerning life-sustaining treatment and/or procedures?
IGN04022
Yes, include nutrition and fluids paragraph.
HCP_MA05
LDo you wish to state your desires regarding artificial nutrition and fluids?
IGN04023
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YesNo
HCP_MA05
Will artificially administered nutrition and fluids be included in the "life-sustaining procedures" that may be withheld or withdrawn?
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Yes, include life-sustaining procedures section.
HCP_MA05
GDo you wish to state your desires regarding life-sustaining procedures?
IGN04003
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Special provisions:#|
HCP_MA06
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_MA07
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.
=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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