[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_MD18
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DESIGNATION OF AGENT. An owner, operator, or employee of a health care facility from which the Declarant is receiving health care may not serve as the Agent unless such person is:
(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.
Enter the name of the person who will be the Agent or use the P.I. Manager to select and paste a record. The Agent will have the authority to make health care decisions for the Declarant if the Declarant is unable to do so.
HMD01017
Relation:#|
HCP_MD01
;What is the Agent's relationship, if any, to the Declarant?
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When the Declarant is incapable of making an informed decision#| When this document is signed
HCP_MD02
1When does the Agent's authority become effective?
Enter an X if the Agent's authority is to become effective only when the Declarant's attending physician and a second physician determine that he/she is incapable of making informed health care decisions.
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Yes, include terminal condition provision.
HCP_MD03
lDo you wish to provide instructions regarding life-sustaining procedures if you are in a TERMINAL CONDITION?
Enter an X to provide instructions regarding life-sustaining procedures and artificial feeding if you are in a TERMINAL CONDITION (death is imminent and there is no reasonable expectation of recovery). If this provision is selected, it must be initialed by the Declarant when this document is signed.
HMD03004
HMD03006
Artificial feeding MAY be withdrawn or withheld.#| Artificial feeding MAY NOT be withdrawn or withheld.
HCP_MD03
VIf you are in a terminal condition, what are your wishes regarding artificial feeding?
HMD03006
Yes, include vegetative state provision.
HCP_MD03
uDo you wish to provide instructions regarding life-sustaining procedures if you are in a PERSISTENT VEGETATIVE STATE?
Enter an X to provide instructions regarding life-sustaining procedures and artificial feeding if you are in a PERSISTENT VEGETATIVE STATE (unconscious and not able to interact with others, and there is no reasonable expectation of recovery). If selected, this provision must be initialed by the Declarant.
HMD03008
HMD03010
Artificial feeding MAY be withdrawn or withheld.#| Artificial feeding MAY NOT be withdrawn or withheld.
HCP_MD03
_If you are in a persistent vegetative state, what are your wishes regarding artificial feeding?
HMD03010
Yes, include end-stage condition provision.
HCP_MD03
nDo you wish to provide instructions regarding life-sustaining procedures if you are in an END-STAGE CONDITION?
Enter an X to provide instructions regarding life-sustaining procedures and artificial feeding if you are in an END-STAGE CONDITION (permanent deterioration and complete physical dependency for which treatment of the irreversible condition would be medically ineffective).
HMD03012
HMD03014
Artificial feeding MAY be withdrawn or withheld.#| Artificial feeding MAY NOT be withdrawn or withheld.
HCP_MD03
XIf you are in an end-stage condition, what are your wishes regarding artificial feeding?
HMD03014
No. Pain medication is to be withheld if it would shorten my remaining life.
HCP_MD03
iDo you wish to receive medication to relieve pain and suffering if it would shorten your life expectancy?
HMD03016
Yes, any and all treatment is desired.
HCP_MD03
6Do you wish to receive all medical treatment possible?
HMD03018
Yes, include pregnancy provision.
HCP_MD03
\Do you wish to state your desires concerning life-sustaining procedures if you are pregnant?
HMD03020
HMD03028
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.#| [Enter description in your own words]
HCP_MD03
JHow will this document be affected if you have been diagnosed as 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.
Enter an X if the Declarant wishes to draft her own provision regarding the effect of her pregnancy on this document. If selected, this provision must be initialed by the Declarant when this document is signed.
HMD03021
HMD03024
Yes, 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.
HCP_MD03
sIf you have been diagnosed as pregnant, do you desire that this document be enforced if the fetus will not survive?
HMD03022
Yes, if life-sustaining procedures will be physically harmful or unreasonably painful to me, I request that such harm or pain be considered in determining whether this document shall be effective if I am pregnant.
HCP_MD03
Do you request that pain or physical harm to you be considered in determining whether life-sustaining procedures or treatment should be withheld or withdrawn?
HMD03028
As follows:#|
HCP_MD03
]How will your decision concerning life-sustaining procedures be modified if you are pregnant?
HMD03028
Other desires/instructions:#|
HCP_MD03
eWhat other desires or special instructions regarding life-sustaining procedures do you wish to state?
If desired, list the Declarant's wishes regarding life-sustaining procedures or any other instructions regarding receipt or nonreceipt of health care procedures. Any additional statements regarding a terminal condition, a persistent vegetative state, or an end-stage condition may be composed.
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HMD03028
Yes, include the section.
HCP_MD03
FDo you wish to state your wishes regarding life-sustaining procedures?
HMD03002
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Special provisions:#|
HCP_MD04
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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HMD04255
Values and preferences:#|
HCP_MD05
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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HMD05255
The Declarant's body#| Any needed organs or partsExcept the following:#| The following organs or parts:
HCP_MD09
(Which organs or tissues will be donated?
HMD09010
The following person or institution:#|
HCP_MD09
;Who, if anyone, will be designated to receive the donation?
If desired, enter the name of the individual or entity that will receive the donated organs, tissues, or parts. Only certain individuals and institutions are authorized to accept organs and tissues. If no recipient is named, the Declarant's organs and tissues will be given to those who can use them.
HMD09013
HMD09010
Any purpose authorized by law.#| The following purposes:TransplantationTherapyMedical researchEducation
HCP_MD09
2For what purposes will the donated organs be used?
HMD09019
Yes, regardless of any other provisions in this document, I direct my attending physician to maintain my organs on artificial support systems after my death until the donated organs and/or tissues are removed.
HCP_MD09
After the Declarant's death, does the Declarant want life-support systems to be used to maintain the donated organs until they can be removed?
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Yes, include the Donation of Organs section.
HCP_MD09
GDoes the Declarant wish to make an organ donation at the time of death?
<Who, if anyone, will be appointed 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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HMD10027
Yes, include Alternate Agent section.
HCP_MD10
,Do you wish to designate an Alternate Agent?
HMD10003
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The Agent or Alternate AgentOther person to be named
;What are the Declarant's county and social security number?
Enter the Declarant's county or edit the information as desired.
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Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_MD17
2What are the names and addresses of the witnesses?
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HMD17002
Limitations:#|
HCP_MD06
nWhat limitations, if any, will there be on the Agent's authority to make decisions on behalf of the Declarant?
If desired, specify any limitations on the Agent's authority. For example, the Declarant may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
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IAR06255
Yes, the Agent will have access to information regarding the Declarant's health.
HCP_MD07
>Will the Agent have access to the Declarant'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 Declarant'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_MD08
NWill the Agent have the power to sign health care documents for the Declarant?
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