This required section states the name and address of the person appointed to make health care decisions if the Patient is unable to do so. There are limits on who may act as the Patient Advocate. Press [Ctrl+F1] for more.
This required section concerns the authority the Patient Advocate is given. The Patient grants full power to the Patient Advocate to make health care decisions if Patient is unable to do so. Press [Ctrl+F1] for more.
This optional section states the Patient's wishes regarding life-sustaining treatments which artificially postpone death, and desires regarding artificial food and nutrition. Press [Ctrl+F1] for more information.
This optional section gives the Patient 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 Patient 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 Patient to establish specific limitations upon the decision making authority of the Patient Advocate. Press [Ctrl+F1] for more information.
This optional section enables the Patient Advocate to request, review and disclose information regarding the physical and mental condition of the Patient. Press [Ctrl+F1] for more information.
This optional section gives the Patient Advocate the authority to sign on behalf of the Patient if the Patient is unable to do so Press [Ctrl+F1] for more information.
This required section describes the events which must occur before the authority granted to the Patient Advocate becomes effective. Press [Ctrl+F1] for more information.
This optional section states that the Patient may designate other Patient Advocates if the original is unavailable or unable to act. Press [Ctrl+F1] for more information.
This required section states that any prior Durable Power of Attorney for Health Care made by the Patient 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 Patient's desires. Press [Ctrl+F1] for more.
By signing this required section, the Patient will acknowledge full understanding of the document contents as well as the effects of the granting of powers to the Patient Advocate. Press [Ctrl+F1] for more.
This section requires the signature of two witnesses to acknowledge that the Patient signed the document. Press [Ctrl+F1] for more information.
This required section requires the Patient Advocate(s) signature. The Patient Advocate(s) agree to serve according to the desires of the Patient as stated in this document. 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_MI
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 "Patient") 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 Patient's city or edit the information as desired.
Enter the Patient's state or edit the information as desired.
Enter an X to include the Patient's country, if outside the United States.
Enter the country or edit the information as desired.
Enter the Patient Advocate's name or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Patient Advocate which appear later in this section. The Patient Advocate will have the authority to make health care decisions for the Patient if the Patient is unable to do so.
Enter the Successor Patient Advocate's name or use the P.I. Manager to select and paste a record. The Successor Patient Advocate must sign the printed document in acceptance of his/her appointment.
Enter the Successor Patient Advocate's name or use the P.I. Manager to select and paste a record. The Second Successor Patient Advocate must sign the printed document in acceptance of his/her appointment.
HMI01
! Designation of Health Care Patient Advocate Section (1 of 18)
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
!. DESIGNATION OF PATIENT ADVOCATE.
I, !, of !, !,
! Country: !,
appoint:
Patient Advocate Name: !
Patient Advocate Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Home Phone: !
Work Phone: !
Relation, if any: !
as my Patient Advocate to make health care and personal decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.
This required section states the name and address of the person appointed as Patient Advocate. The Patient Advocate will make health care decisions for the Patient if the Patient 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 "Patient") 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 Patient's city or edit the information as desired.
Enter the Patient's state or edit the information as desired.
Enter an X to include the Patient's country, if outside the United States.
Enter the country or edit the information as desired.
Enter the Patient Advocate's name or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Patient Advocate which appear later in this section. The Patient Advocate will have the authority to make health care decisions for the Patient if the Patient is unable to do so.
Enter the Patient Advocate's street address or edit the information as desired.
Enter the Patient Advocate's extended street address or edit the information as desired.
Enter the Patient Advocate's city or edit the information as desired.
Enter the Patient Advocate's state/province or edit the information as desired. When naming a Patient Advocate, consider the availability of the Patient Advocate to confer with health care providers and access medical records and information.
Enter the Patient Advocate's zip/postal code or edit the information as desired.
Enter an X to include the Patient Advocate's country. If the Patient Advocate resides in a different country, he/she may not be available to discuss medical decisions with the health care providers.
Enter the Patient Advocate's country or edit the information as desired.
Enter a phone number at which the Patient Advocate may be reached during non-business hours.
Enter a phone number at which the Patient Advocate may be reached during business hours, if different from the home phone number.
Enter the relationship of the Patient Advocate to the Patient.
HMI02
! Authority of Patient Advocate Section (2 of 18)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, when I am unable to participate in medical treatment decisions, I grant my Patient Advocate full power and authority to make care, custody, and medical treatment 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 Patient Advocate 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 Patient Advocate shall act consistently with my desires as stated in this document or otherwise made known to my Patient Advocate. If my desires regarding any particular care, custody or medical treatment decision are not known to my Patient Advocate, then the decision should be made taking into consideration in my best interests.
This required section states the duties and powers of the Patient Advocate on behalf of the Patient. The health care decisions made by the Patient Advocate must be consistent with the desires of the Patient as stated in this document, or otherwise known by the Patient Advocate. Press [Ctrl+F1] for more information.
HMI03
! Optional Life-Sustaining Treatment Section (3 of 18)
!. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING CARE, TREATMENT, SERVICES AND PROCEDURES: [Choose one of 5 choices; last choice allows you to compose your own statement.]
! I do not want my life to be prolonged nor do I want life-sustaining treatment to be provided or continued if my Patient Advocate believes the burdens of the treatment outweigh the expected benefits. I want my Patient Advocate to consider the relief of suffering, the expense involved and the quality as well as the possible extension of my life in making decisions concerning life-sustaining treatment. I UNDERSTAND THAT SUCH A DECISION COULD OR WOULD ALLOW ME TO DIE.
! 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 coma or persistent vegetative state 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 coma or persistent vegetative state which is reasonably concluded to be irreversible.
I UNDERSTAND THAT SUCH A DECISION COULD OR WOULD ALLOW ME TO DIE.
! I want my life to be prolonged to the greatest extent possible 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.]
! I UNDERSTAND THAT SUCH A DECISION COULD OR WOULD ALLOW ME TO DIE.
! [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
! 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 Patient'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 Patient DOES NOT wish to prolong life or be provided with life-sustaining treatment if the Patient Advocate feels the burdens of treatment outweigh the benefits.
Enter an X if the Patient desires life-sustaining treatment to be given only to the extent of providing the Patient with comfort.
Enter an X to withhold life-sustaining treatment if the condition of the Patient is incurable or irreversible.
Enter an X to withhold life-sustaining treatment if the Patient is in a permanently unconscious condition.
Enter an X to withhold life-sustaining treatment if the Patient's condition is incurable or if the Patient is in a permanently unconscious state.
Enter an X if the Patient desires every possible treatment be taken to prolong life to the greatest extent, regardless of cost or chances for recovery.
Enter an X if the Patient 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 if the composed statement describes actions that may result in the Patient's death.
Enter an X to include a section regarding artificially administered nutrition and fluids.
Enter an X if artificial nutrition and fluids SHALL be among the life-sustaining treatment that may be withdrawn or withheld by the Patient Advocate's authorization.
Enter an X if artificial nutrition and fluids SHALL NOT be among the life-sustaining treatment that may be withdrawn or withheld by the Patient Advocate's authorization.
IGN06
! 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, 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 (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.
HMI06
! Optional Limits on Patient Advocate's Authority Section (6 of 18)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY PATIENT ADVOCATE:
Enter an X to include a section that allows the Patient to establish limitations on the authority given to the Patient Advocate. For example, the Patient may wish to prohibit the Patient Advocate from authorizing certain procedures. Press [Ctrl+F1] for more information.
Use this space to specify any limitations on the Patient Advocate's authority to make decisions on behalf of the Patient.
HMI07
! Optional Inspection and Disclosure of Information Section (7 of 18)
!. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my Patient Advocate 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 Patient Advocate to request, review, and disclose any information regarding the physical or mental condition of the Patient. Press [Ctrl+F1] for more information.
HMI08
! Optional Signing Documents, Waivers, and Releases Section (8 of 18)
!. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to implement the health care decisions that my Patient Advocate is authorized by this document to make, my Patient Advocate 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.
Enter an X to include a section which gives the Patient Advocate the power to sign health care documents (such as admission, discharge, consent, or release forms) on behalf of the Patient. The Patient Advocate is NOT responsible for the cost of any medical service provided to the Patient. Press [Ctrl+F1].
HMI09
! Duration Section (9 of 18)
!. DURATION. All authority granted to my Patient Advocate shall be exercisable only when I am unable to participate in medical treatment decisions. My attending physician and one other physician or licensed psychologist shall make the determination as to when I am unable to participate in medical treatment decisions, which determination shall be put in writing and made a part of my medical record, and shall be reviewed not less than annually. All powers conferred on my Patient Advocate shall be suspended if I regain the ability to participate in medical treatment decisions. The powers granted to my Patient Advocate shall become effective again if I am later determined unable to participate in medical treatment decision in the manner described.
This required section describes the events which must occur before the authority granted to the Patient Advocate becomes effective. Press [Ctrl+F1] for more information.
HMI10
! Optional Designation of Successor Patient Advocate Section (10 of 18)
!. DESIGNATION OF SUCCESSOR PATIENT ADVOCATE. If the person designated as my Patient Advocate is not available or unable to act, I designate the following persons to serve as my Patient Advocate to make health care decisions for me as authorized by this document, who serve in the following order:
FIRST SUCCESSOR PATIENT ADVOCATE
Patient Advocate Name: !
Patient Advocate Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Home Phone: !
Work Phone: !
SECOND SUCCESSOR PATIENT ADVOCATE
Patient Advocate Name: !
Patient Advocate Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Home Phone: !
Work Phone: !
Enter an X to designate a Successor Patient Advocate. If the original Patient Advocate resigns or is unable to perform, a Successor Patient Advocate will be appointed. Generally, the designation of the Patient's spouse as Patient Advocate is revoked upon divorce. Press [Ctrl+F1] for more information.
Enter the Successor Patient Advocate's name or use the P.I. Manager to select and paste a record. The Successor Patient Advocate must sign the printed document in acceptance of his/her appointment.
Enter the Successor Patient Advocate's street address or edit the information as desired.
Enter the Successor Patient Advocate's extended street address or edit the information as desired.
Enter the Successor Patient Advocate city or edit the information as desired.
Enter the Successor Patient Advocate's state/province or edit the information if desired. When naming a Successor Patient Advocate, consider the availability of the Successor Patient Advocate to confer with health care providers.
Enter the Successor Patient Advocate's zip/postal code or edit the information as desired.
Enter an X to include the Successor Patient Advocate's country. If the Successor Patient Advocate resides in a different country, consider the availability of the Successor Patient Advocate 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 Successor Patient Advocate may be reached during non-business hours.
Enter a phone number at which the Successor Patient Advocate may be reached during business hours, if different from the home phone number.
Enter an X to include the name of a second Successor Patient Advocate. You do not have to name a second Successor Patient Advocate.
Enter the Successor Patient Advocate's name or use the P.I. Manager to select and paste a record. The Second Successor Patient Advocate must sign the printed document in acceptance of his/her appointment.
HMI11
! Revocation Section (11 of 18)
!. PRIOR DESIGNATIONS REVOKED. I revoke any prior Designation of a Patient Advocate.
This required revocation section states that any prior Designation of Patient Advocate for Health Care made by the Patient is revoked. Press [Ctrl+F1] for more information.
IGN16
! Hold Harmless Section (12 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 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 (13 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.
IGN18
! Statement of Intentions Section (14 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 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.
HMI15
! Signature Section (15 of 18)
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I have read and understand the contents of this document and the effect of this grant of powers to my Patient Advocate. I am at least eighteen years old, and am providing these instructions of my free will. I am emotionally and mentally competent to make this declaration.
This section requires the signature of the Patient in the presence of two witnesses or a Notary Public. If this procedure is not followed, the document may be invalid. Press [Ctrl+F1] for more information.
Enter the Patient's county/parish or edit the information. The Patient's name and address was transferred from a previous section and can be modified only by returning to that section.
Enter an X to include the Patient'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 Patient's social security number or edit the information.
HMI16
! Witness Statement Section (16 of 18)
TO BE EFFECTIVE THIS DESIGNATION MUST BE SIGNED IN THE PRESENCE OF TWO WITNESSES.
STATEMENT OF WITNESSES
We declare that the person who signed this Designation of Patient Advocate is personally known to us, that he/she signed this document in our presence, and that he/she appeared to us to be of sound mind and under no duress, fraud or undue influence. We are not the spouse, parent, child, grandchild, sibling, physician, presumptive heir, or known beneficiary of the will at the time of witnessing of the person who signed this instrument. We are not named as the Patient Advocate or a Successor Patient Advocate in this document. Nor are we an employee of a life or health insurance provider for, or a health facility that is treating, the person who signed this instrument, nor are we an employee of the home for the aged where the person who signed this instrument resides. We are at least eighteen years old.
This section requires the signature of two witnesses. By signing this section, the witnesses declare that they were present when the Patient 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.
HMI17
! Patient Advocate Acceptance Section (17 of 18)
[The Patient Advocate (and any Successor Patient Advocates) must sign this document.]
PATIENT ADVOCATE ACCEPTANCE OF DESIGNATION
The Patient Advocate/Successor Patient Advocate(s) accept(s) the Patient's designation as stated in this document and agree(s) that:
a. This designation shall not become effective unless the Patient is unable to participate in medical treatment decisions.
b. A Patient Advocate shall not exercise powers concerning the Patient's care, custody, and medical treatment that the Patient, if the Patient were able to participate in the decision, could not have exercised on his or her own behalf.
c. This designation cannot be used to make a medical treatment to withhold or withdraw treatment from a Patient who is pregnant that would result in the pregnant Patient's death.
d. A Patient Advocate may make a decision to withhold or withdraw treatment which would allow a patient to die only if the Patient has expressed in a clear and convincing manner that the Patient Advocate is authorized to make such a decision, and that the Patient acknowledges that such a decision could or would allow the Patient's death.
e. A Patient Advocate shall not receive compensation for the performance of his or her authority, rights, and responsibilities, but a Patient Advocate may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities.
f. A Patient Advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the Patient and shall act consistent with the Patient's best interest. The known desires of the Patient expressed or evidenced while the Patient is able to participate in medical treatment decisions are presumed to be in the Patient's best interests.
g. A Patient may revoke his or her designation at any time and in any manner sufficient to communicate an intent to revoke.
h. A Patient Advocate may revoke his or her acceptance to the designation at any time and in any manner sufficient to communicate an intent to revoke.
i. A Patient admitted to a health facility or agency has the rights enumerated in Section 20201 of the Public Health Code, Act No. 368 of Public Acts of 1978, being Section 333.20201 of the Michigan Compiled Laws.
This required section states the Patient Advocate understands and agrees to the contents of this document which outlines the duties and responsibilities of the Patient Advocate. The names have been transferred from a previous section and can be modified only by returning to that section. Press [Ctrl+F1] for more information.
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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