[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_MO23
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NOTE: YOUR AGENT MAY NOT BE your attending physician or an employee of your attending physician, or an owner, operator or employee of a health care facility in which you are a resident, shall not serve as your Attorney-in-Fact unless: (1) You are related by affinity or consanguinity within the second degree; or (2) You are members of the same community of persons who are bound by vows to a religious life and who conduct or assist in the conducting of religious services and actually and regularly engage in religious, benevolent, charitable, or educational ministry, or the performance of health care services.
HCP_MO01
HMO01007
Name: |City: |State: |[Include country]Country: |
HCP_MO01
EWho is this Durable Health Care Power of Attorney being prepared for?
Enter the Agent's name 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 Principal if the Principal is unable to do so.
HMO01019
Relation:#|
HCP_MO01
;What is the Agent's relationship, if any, to the Principal?
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HCP_MO02
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HCP_MO03
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Yes, specify procedures to be withdrawn.
HCP_MO04
Do you want to specify which life-prolonging procedures should be withheld or withdrawn if you are permanently unconscious or in a terminal condition?
HMO04004
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Surgery or other invasive proceduresHeart-lung resuscitation (CPR)AntibioticDialysisMechanical ventilator (respirator)ChemotherapyRadiation therapyAll other "life-prolonging" medical or surgical procedures
HCP_MO04
Which life-prolonging procedures should be withheld or withdrawn if you are permanently unconscious or in a terminal condition?
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Yes, include life-prolonging procedures section.
HCP_MO04
GDo you wish to state your desires regarding life-prolonging procedures?
HMO04002
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YesNo
HCP_MO05
Will the Agent have the authority to make decisions regarding the withdrawal of any artificially supplied nutrition and/or fluids?
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Yes, include nutrition/fluids section.
HCP_MO05
[Do you wish to state your desires regarding artificially administered nutrition and fluids?
HMO05002
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Yes, the Agent will have access to information regarding the Principal's health.
HCP_MO09
>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 sign such documents for the Principal.
HCP_MO10
VWill the Agent be authorized to sign health care documents on behalf of the Principal?
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HCP_MO12
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Yes, I want one physician, instead of two, to decide whether I am incapacitated.
HCP_MO13
rDo you wish to state that only ONE physician is required to determine your capacity to make health care decisions?
This document shall become effective when TWO physicians validate that the Principal cannot make decisions for him/herself. Enter an X if the Principal desires the opinion of only ONE physician to decide if the Principal is incapacitated. The Principal must initial this option on the printed document.
<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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HMO14031
Yes, include Alternate Agent section.
HCP_MO14
,Do you wish to designate an Alternate Agent?
HMO14002
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HCP_MO16
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HCP_MO17
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HCP_MO18
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County: |[Include SSN]SSN: |
HCP_MO20
;What are the Principal's county and social security number?
Enter the Principal's county/parish or edit the information as desired.
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Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_MO21
2What are the names and addresses of the witnesses?
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HMO21002
HCP_MO22
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Limitations:#|
HCP_MO08
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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IAK09255
Special provisions:#|
HCP_MO06
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_MO07
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
Agent (or Alternate)Other person
HCP_MO15
YWho do you nominate to be appointed as Guardian, if one is required by legal proceedings?
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