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 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 Principal is unable to do so. Press [Ctrl+F1] for more information.
This optional section states the Principal's wishes regarding life-sustaining procedures which artificially postpone death and desires regarding artificial feeding. 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 optional 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 optional 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 optional section allows the Declarant to make anatomical gifts and to state that life-sustaining procedures may be used until organ donations can be made
This optional section states that if the original Agent is not available, an alternate Agent will assume the duties 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 that any prior Advance Medical Directive 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 recognized as 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 effect 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 the limits on who may act as a witness. 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_MD
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 "Declarant") 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 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 Maryland.
Enter an X to include the Declarant's country, if outside the United States.
Enter the name of the country or edit the information as desired.
HMD01
! Designation of Health Care Agent Section (1 of 18)
ADVANCE DIRECTIVE
!. DESIGNATION OF HEALTH CARE AGENT.
I, !, of !, !,
! Country: !,
appoint:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
as my Agent to make health care decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.
NOTICE: An owner, operator, or employee of a health care facility from which the Declarant is receiving health care may not serve as a health care agent unless such person has a close connection with the patient:
1. Appointed as guardian for the patient;
2. The patient's spouse;
3. An adult child of the patient;
4. A parent of the patient;
5. An adult sibling of the patient; or
6. A friend or other relative who is a competent individual, and presents an affidavit to the attending physician stating specific facts and circumstances which demonstrate that the person has maintained regular contact with the patient sufficient to be familiar with the patient's activities, health and personal beliefs.
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 the Declarant 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 "Declarant") 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 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 Maryland.
Enter an X to include the Declarant's country, if outside the United States.
Enter the name of 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 to access medical records and information.
Enter the Agent's zip/postal code or edit the information as desired.
Enter an X to include the name of 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 providers.
Enter the country or edit the information as desired.
Enter a phone number or one 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.
Enter the relationship of the Agent to the Declarant.
HMD02
! Authority of Agent Section (2 of 18)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any provisions or 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. My agent is to make health care decisions for me based on the health care instructions I give in this document and on my wishes as otherwise known to my agent. If my wishes are unknown or unclear, my agent is to make health care decisions for me in accordance with my best interest, to be determined by my agent after considering the benefits, burdens, and risks that might result from a given treatment or course of treatment, or from the withholding or withdrawal of a treatment or course of action. My agent shall not be liable for the costs of care based solely on this authorization.
My agent's authority becomes operative
! when my attending physician and a second physician determine that I am incapable of making an informed decision regarding my health care.
! when this document is signed.
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.
Enter an X if the Agent's authority will become effective only when the Declarant is incapable of making health care decisions.
Enter an X if the Agent's authority will become effective when this document is signed.
'HMD03
! Optional Life-Sustaining Procedures (3 of 18)
!. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING CARE, TREATMENT, SERVICES AND PROCEDURES. (INITIAL ALL THOSE THAT APPLY)
If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions as set forth below.
! !. If my death from a TERMINAL CONDITION is imminent and even if life-sustaining procedures are used there is no reasonable expectation my recovery:
! _____ I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
! _____ I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food by month, I wish to receive nutrition and hydration artificially.
!. If I am in a PERSISTENT VEGETATIVE STATE, that is, if I am not conscious and am not aware of my environment or able to interact with others, and there is no reasonable expectation of my recovery:
! _____ I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
! _____ I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially.
!. If I have an END-STAGE CONDITION, that is a condition caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective:
! _____ I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
! _____ I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially.
!. _____ I direct that no matter what my condition, medication not be given to me to relieve pain and suffering, if it would shorten my remaining life.
!. _____ I direct that no matter what my condition, I be given all available medical treatment in accordance with accepted health care standards.
!. If I am pregnant, my decision concerning life-sustaining procedures shall be modified as follows:
! _____ If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point.
! If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
! _____
!. _____ [User to compose own statement of desires concerning life-sustaining procedures and/or other instructions regarding receipt or nonreceipt of any health care.]
Enter an X to include a section concerning the Declarant's wishes regarding life-sustaining procedures. Press [Ctrl+F1] for more information.
Enter an X to provide instructions regarding life-sustaining procedures and artificial feeding if the Declarant is in a TERMINAL CONDITION. The provision that you select must be initialed by the Declarant when this document is signed.
Enter an X if the Declarant's life should not be extended by life-sustaining procedures if the Declarant is in a TERMINAL CONDITION. The Declarant includes artificial feeding as a type of life-sustaining procedure which may be withdrawn or withheld.
Enter an X if the Declarant's life should not be extended by life-sustaining procedures if the Declarant is in a TERMINAL CONDITION. The Declarant DOES NOT include artificial feeding as a type of life-sustaining procedure which may be withdrawn or withheld.
Enter an X to provide instructions regarding life-sustaining procedures and artificial feeding if the Declarant is in a PERSISTENT VEGETATIVE STATE. The provision that you select must be initialed by the Declarant when this document is signed.
Enter an X if the Declarant's life should not be extended by life-sustaining procedures if the Declarant is in a PERSISTENT VEGETATIVE STATE. The Declarant includes artificial feeding as a type of life-sustaining procedure which may be withdrawn or withheld.
Enter an X if the Declarant's life should not be extended by life-sustaining procedures if the Declarant is in a PERSISTENT VEGETATIVE STATE. The Declarant DOES NOT include artificial feeding as a type of life-sustaining procedure which may be withdrawn or withheld.
Enter an X to provide instructions regarding life-sustaining procedures and artificial feeding if the Declarant is in an END-STAGE CONDITION. The provision that you select must be initialed by the Declarant when this document is signed.
Enter an X if the Declarant's life should not be extended by life-sustaining procedures if the Declarant is in an END-STAGE CONDITION. The Declarant includes artificial feeding as a type of life-sustaining procedure which may be withdrawn or withheld.
Enter an X if the Declarant's life should not be extended by life-sustaining procedures if the Declarant is in an END-STAGE CONDITION. The Declarant DOES NOT include artificial feeding as a type of life-sustaining procedure which may be withdrawn or withheld.
Enter an X if the Declarant DOES NOT want pain medication if it would shorten the Declarant's life expectancy. If this provision is selected, it must be initialed by the Declarant when this document is signed.
Enter an X if the Declarant DESIRES that all medical treatment be provided, including life-sustaining procedures, even if the Declarant is in a terminal condition, persistent vegetative state, or end-stage condition. If selected, this provision must be initialed by the Declarant when the document is signed.
Enter an X if the Declarant is female, and desires to indicate the effectiveness of this document if she is pregnant.
Enter an X if this document should not be effective if the Declarant is pregnant. If selected, this provision must be initialed by the Declarant when the document is signed. Later in this section, an alternative is presented which allows the Declarant to draft her own provision regarding pregnancy.
Enter an X if the Declarant desires that this document be effective only if the fetus could not develop to the point of live birth with the continued application of life-sustaining procedures. In other words, life-sustaining procedures would be used if the fetus might live.
Enter an X if the Declarant desires that her physical comfort be taken into consideration in determining whether this document should be effective if she is pregnant, and if the application of life-sustaining procedures will be unreasonably painful.
Enter an X to draft a provision regarding pregnancy. If selected, this provision must be initialed by the Declarant when this document is signed.
Use this space to compose a statement regarding the Declarant's desires regarding the effectivity of this document if she is pregnant.
Enter an X to compose a statement of the Declarant's desires concerning life-sustaining procedures, or any other instructions regarding receipt of health care procedures. Any of the above statements may be edited or additional statements may be composed.
Use this space to compose a statement regarding the receipt or nonreceipt of health care procedures.
HMD04
! Optional Special Provisions Section (4 of 18)
!. 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, specify any types of treatment desired or not desired. Press [Ctrl+F1] for more information.
Use this space to include additional special provisions.
HMD05
! Optional Values and Preferences Section (5 of 18)
!. 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 18)
!. 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 18)
!. 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 18)
!. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. My agent has full power and authority to employ and discharge health care providers. 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, hospice, nursing home, adult home, or other medical care facility.
b. Documents titled or purporting to be "Consent to Permit Treatment" or "Refusal to Permit Treatment".
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.
HMD09
! Optional Donation of Organs Section (9 of 18)
I give
! my body
! any needed organs, tissues, or parts
! except
! the following organs, tissues, or parts:
! to the following named physician, hospital, tissue bank, or other medical institution:
! for any purpose authorized by law.
! for the following purposes:
! transplantation
! therapy
! medical research
! education
! _______________________________________
purposes.
Notwithstanding the other provisions of this document, if I have been determined to be dead according to law, I direct my attending physician to maintain my organs on artificial support systems only for the period of time required to maintain the viability of and to remove the donated organs and/or tissues.
Enter an X to include an optional section which allows the Declarant to make an organ donation, and to designate which organs, tissues, or parts the Declarant desires to donate at the Declarant's death. Press [Ctrl+F1] for more information.
Enter an X if the Declarant desires to donate his or her body at the Declarant's death.
Enter an X if the Declarant desires that any needed organs, tissues, or parts be donated at the Declarant's death.
Enter an X to list one or two specific organs that the Declarant DOES NOT want removed at death.
Enter a description of the specific organs, tissues, or parts that should not be removed from the Declarant's body at death. For example, enter the word "heart" or "eyes".
Enter an X if the Declarant desires to specify only selected organs, tissues, or parts to be removed upon the Declarant's death.
Enter a description of the selected organs, tissues, or parts to be removed upon the Declarant's death. For example, heart, heart valves, lungs, kidneys, liver, pancreas, intestines, bone, skin, blood vessels, eyes, musculoskeletal structures, or body fluids.
Enter an X to include a designation of an individual or institution to receive the donation. If this section is not included, the Declarant's organs and tissues will be given to individuals or institutions who can use them.
Enter the name of the individual or entity to receive the donated organs, tissues, or parts. Only certain individuals and institutions are authorized to accept organs and tissues. For more help, access Document Information regarding acceptable donees.
Enter an X if the Declarant desires to donate organs, tissues, or parts to be used for any purpose authorized by law.
Enter an X to state the purpose for which the donation may be used. Such purposes include: transplantation, therapy, medical research and education.
Enter an X if the Declarant desires the organs, tissues, or parts be used for transplantation.
Enter an X if the Declarant desires that the organs, tissues, or parts be used for therapy. Some organs and tissues provide essential treatment for patients who do not necessarily need a transplant.
Enter an X if the Declarant desires that the organs, tissues, or parts be used for research. Organs and tissues that are not suitable for transplantation or therapy are needed in medical research.
Enter an X if the Declarant desires that the organs, tissues, or parts be used for education. Donated organs and tissues can play an important role in medical education.
Enter an X if the Declarant directs that artificial support procedures should be used to maintain the Declarant's body until organization donation wishes can be met.
HMD10
! Optional Designation of Alternate Agent Section (10 of 18)
!. 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 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.
HMD11
! Optional Nomination of Guardian Section (11 of 18)
!. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate
! my Agent (or Alternate Agent)
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
to serve as my Guardian.
Enter an X to include a section that allows the Declarant to nominate a person to serve as the Declarant's Guardian if one is required by legal proceedings. This person will be appointed if the Court finds that such appointment is in the Declarant's best interests. Press [Ctrl+F1] for more information.
Enter an X if the nominated Guardian should be the Agent or Alternate Agent.
Enter an X if the nominated Guardian will someone other than the Agent or Alternate Agent.
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 Declarant.
Enter the Guardian's state/province or edit the 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, if outside the United States. It is very unlikely that a court would appoint a person living in another country as a Guardian for the Declarant.
Enter the country or edit the information as desired.
HMD12
! Revocation Section (12 of 18)
!. PRIOR DESIGNATIONS REVOKED. I revoke any prior Health Care Power of Attorney or Advance Directive.
This required revocation section states that any prior Health Care Power of Attorney or Advance Directive made by the Declarant is revoked. Press [Ctrl+F1] for more information.
HMD13
! Hold Harmless Section (13 of 18)
!. 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.
HMD14
! Severability Section (14 of 18)
!. 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.
HMD15
! Statement of Intentions Section (15 of 18)
!. 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 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.
HMD16
! Signature Section (16 of 18)
(YOU MUST DATE AND SIGN THIS DOCUMENT
IN THE PRESENCE OF TWO WITNESSES)
By signing below, I indicate that I am emotionally and mentally competent to make this Advance Directive and that I understand the purpose and effect of this document.
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 Declarant's county/parish or edit the information. The Declarant's name and address were 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 as desired.
HMD17
! Witness Signature Section (17 of 18)
STATEMENT OF WITNESSES
The declarant signed or acknowledged signing this Advance Directive in my presence and based upon my personal observation the declarant appears to be a competent individual. I am not the person appointed as the Health Care Agent or Alternate Health Care Agent by this document.
I further declare that to the best of my knowledge, I am not entitled to any portion of the estate of the declarant or entitled to any financial benefit by reason of the death of the declarant.
This section requires the signatures 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 a 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.
DOM01
! Health Care Document Information Section (18 of 18)
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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