[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_NC19
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This section contains a Disclosure Statement which explains the purpose and consequences of this Power of Attorney for Health Care. The Disclosure Statement will appear on the printed document and must be read and understood by the Principal before he or she signs the Power of Attorney for Health Care. Press [Ctrl+F1] for more information.
HCP_NC01
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Name: |City: |State: |[Include country]Country: |
HCP_NC02
=Who is this 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 you if you are unable to do so. Any competent person who is not providing health care to the Principal for remuneration, and who is 18 or older, may act as a Health Care Agent.
HNC02019
Relation:#|
HCP_NC02
;What is the Agent's relationship, if any, to the Principal?
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Yes, a specific physician will be named.
HCP_NC03
uDo you wish to name a certain physician who will determine your capacity or incapacity to make health care decisions?
This document shall become effective when the Principal's physician determines that the Principal is unable to make health care decisions. Enter an X if the Principal desires the determination of his/her capacity or incapacity to make decisions is to be made by a specific physician.
HNC03005
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Name: |[Include second physician]Name: |
HCP_NC03
oWhat is the name of the physician who will determine your capacity or incapacity to make health care decisions?
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HCP_NC04
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HCP_NC05
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Yes, I desire that my life not be prolonged by life-sustaining procedures if I am terminally ill, am in a permanent coma, suffer severe dementia, or am in a persistent vegetative state. I DO request care that will provide comfort or alleviate pain.
HCP_NC06
xDo you wish not to receive life-sustaining procedures if you are terminally ill or are in a persistent vegetative state?
Enter an X if the Principal does not wish to receive life-sustaining procedures (procedures which artificially postpone death) if he or she has any of the conditions listed. These procedures do NOT include care necessary to provide comfort or alleviate pain. Press [Ctrl+F1] for more information.
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YesNo
HCP_NC07
Will artificially provided nutrition and fluids be included in the "life-sustaining treatment" that may be withheld or withdrawn?
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Yes, include the section.
HCP_NC07
[Do you wish to state your desires regarding artificially administered nutrition and fluids?
HNC07003
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Special provisions:#|
HCP_NC08
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, or state whether you wish to be admitted to a residential care facility. Press [Ctrl+F1] for more information.
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HNC08255
Values and preferences:#|
HCP_NC09
eWhat values and preferences, if any, concerning your health care should be included in this document?
If desired, use this space to specify values and preferences. For example, describe your 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. Press [Ctrl+F1] for more information.
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HNC09255
Limitations:#|
HCP_NC10
nWhat limitations, if any, will there be on the Agent's authority to make decisions on behalf of the Principal?
If desired, use this space to specify any limitations on the Agent's authority to make decisions on behalf of the Principal. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
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HNC10255
YesNo
HCP_NC11
Will the Agent be authorized to make decisions concerning organ donation, an autopsy, and the disposition of the Principal's remains?
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