This required section states the basic purpose for this document. It is important for the Principal to understand the rights and duties of all parties before executing this document. Press [Ctrl+F1] for more information.
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 more information.
This required section creates a Durable Power of Attorney for Health Care. It shall be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more 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 the Principal is unable to do so. Press [Ctrl+F1] for more information.
This optional section states the Principal's wishes regarding life-sustaining treatments which artificially postpone death. Press [Ctrl+F1] for more information.
This optional section states that the Principal may decide whether artificial nutrition and fluids shall or shall not be among the life-sustaining treatments provided. 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 gives the Agent the authority to make anatomical gifts for medical purposes. 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 required section states this document will exist indefinitely unless otherwise specified. Press [Ctrl+F1] for more information.
This section states that if the original Agent is not available, an alternate Agent will assume responsibility of the original Agent. Press [Ctrl+F1] for more information.
This required section states that any prior Durable Power of Attorney made by the Principal is revoked. 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 effects 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 limits on who may act as a witness. Press [Ctrl+F1] for more information.
This section requires the signatures of the Agent and the alternate Agent agreeing to act as the Principal's health care Agent and to follow the Principal's wishes. Press [Ctrl+F1] for more information.
Select this optional section if the Principal is admitted to a hospital or a long term care facility. A special statement will be required from the institution. 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_ND
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 Principal's city or edit the information as desired.
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
This is a state-specific document. Enter the Principal's state/province or edit the information as desired. The state in this field should be the same as the state shown at the top of the screen.
Enter an X to include the Principal's country, if outside the United States.
Enter the Principal's country or edit the information as desired.
Enter the Agent's name 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 Principal if the Principal is unable to do so.
Enter the Alternate Agent's name or use the P.I. Manager to select and paste a record. The Alternate Agent must sign the printed document to indicate that he or she accepts this appointment and agrees to follow the Principal's wishes as stated in this document. Press [Ctrl+F1] for more information.
HND01
! Disclosure Statement Section (1 of 20)
WARNING TO PERSON EXECUTING THIS DOCUMENT
This is an important legal document that is authorized by the general laws of this state. Before executing this document, you should know these important facts:
You must be at least eighteen years of age for this document to be legally valid and binding.
This document gives the person you designate as your Agent (the Attorney-in-Fact) the power to make health care decisions for you. Your Agent must act consistently with your desires as stated in this document or otherwise made known.
Except as you otherwise specify in this document, this document gives your Agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.
Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision.
This document gives your Agent authority to request, consent to, refuse to consent to, or to withdraw consent for any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition if you are unable to do so yourself. This power is subject to any statement of your desires and any limitation that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your Agent to make health care decisions for you if your Agent authorizes anything that is illegal; acts contrary to your known desires; or where your desires are not known, does anything that is clearly contrary to your best interest.
Unless you specify a specific period, this power will exist until you revoke it. Your Agent's power and authority ceases upon your death.
You have the right to revoke the authority of your Agent by notifying your Agent or your treating doctor, hospital, or other health care provider orally or in writing of the revocation.
Your Agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.
This document revokes any prior Durable Power of Attorney for Health Care.
You should carefully read and follow the witnessing procedure described at the end of this form. This document will not be valid unless you comply with the witnessing procedure.
If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.
Your Agent may need this document immediately in case of an emergency that requires a decision concerning your health care. Either keep this document where it is immediately available to your Agent and Alternate Agents, if any, or give each of them an executed copy of this document. You should give your doctor an executed copy of this document.
It is important that this section be read in order to understand the purpose of this document, and the rights and obligations of the person making the document (the "Principal") and the person appointed to make health care decisions (the "Agent").
IID01
! Designation of Health Care Agent Section (2 of 20)
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
!. DESIGNATION OF HEALTH CARE AGENT.
I, !, of
!, ! !,
! Country: !,
do hereby designate and appoint:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
(None of the following may be designated as your Agent: (1) your treating health care provider, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility, or (4) a nonrelative employee of an operator of a community care facility.)
as my Attorney-in-Fact (Agent) to make health care decisions for me as authorized in this document. For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical condition.
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 Principal if the Principal 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 "Principal") 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 Principal's street address or edit the information as desired.
Enter the Principal's extended street address or edit the information as desired.
Enter the Principal's city or edit the information as desired.
This is a state-specific document. Enter the Principal's state/province or edit the information as desired. The state in this field should be the same as the state shown at the top of the screen.
Enter the Principal's zip/postal code or edit the information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the Principal's country or edit the information as desired.
Enter the Agent's name 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 Principal if the Principal 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 access medical records and information.
Enter the Agent's zip/postal code or edit the information as desired.
Enter an X to include the Agent's country. If the Agent resides in a different country, he/she may not be available to access medical records or discuss medical decisions with the health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Agent may be reached during non-business hours.
Enter a phone number at which the Agent may be reached during business hours, if different from the home phone number.
Enter the relationship of the Agent to the Principal.
IND03
! Creation of Durable Power of Attorney for Health Care Section (3 of 20)
!. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care.
This required section states that a Durable Power of Attorney for Health Care is being created. Press [Ctrl+F1] for more information.
HND04
! Agent's Authority Section (4 of 20)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I hereby 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. In exercising this authority, my Agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my Agent, including my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures.
(If you want to limit the authority of your Agent to make health care decisions for you, you can state the limitations in paragraph 4 below. You can indicate your desires by including a statement of your desires in the same paragraph.)
!. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. In exercising the authority under this Durable Power of Attorney for Health Care, my Agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated below:
This required section states the general duties and powers of the Agent on behalf of the Principal. The health care decisions made by the Agent must be consistent with the desires of the Principal as stated in this document, or otherwise known to the Agent. Press [Ctrl+F1] for more information.
HND05
! Optional Life-Prolonging Treatment Section (5 of 20)
!. STATEMENT OF DESIRES CONCERNING LIFE-PROLONGING CARE, TREATMENT, SERVICES AND PROCEDURES: [Choose one of 5 choices; last choice allows you to compose your own statement.]
! I specifically direct my Agent to follow any "living will" executed by me.
! I do not want my life to be prolonged nor do I want life-prolonging treatment to be provided or continued if my Agent believes the burdens of the treatment outweigh the expected benefits. I want my Agent to consider the relief of suffering, my personal beliefs, the expense involved and the quality as well as the possible extension of my life in making decisions concerning life-prolonging treatment.
! I do not want my life to be prolonged and I do not want life-prolonging 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-prolonging treatment, expected to result in death within a relatively short time.
! if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! if I have a condition that is incurable or irreversible and, without the administration of life-prolonging treatment, expected to result in death within a relatively short time, or if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! I want my life to be prolonged to the greatest extent possible within the standards of accepted medical practice, 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-prolonging treatment]
Enter an X to include a section concerning the Principal's wishes regarding life-prolonging 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 Agent is to follow any "living will" executed by the Principal. A living will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that life-prolonging treatment be withdrawn or withheld under certain conditions.
Enter an X if the Principal gives the Agent the discretion to decide if and when life-prolonging treatment may be withdrawn or withheld. The Agent will decide if the burdens of treatment outweigh the benefits.
Enter an X if the Principal desires life-prolonging treatment be given only to the extent of providing the Principal with comfort care.
Enter an X to withhold life-prolonging treatment if the condition of the Principal is incurable or irreversible.
Enter an X to withhold life-prolonging treatment if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-prolonging treatment if the Principal's condition is incurable or if the Principal is in a permanently unconscious state.
Enter an X if the Principal desires every possible procedure to be taken to prolong life to the greatest extent, regardless of cost or chances for recovery.
Enter an X if the Principal desires to compose a separate statement of desires concerning life-prolonging treatment. Any of the above statements may be edited or additional statements may be composed.
Use this space to state any other desires concerning life-prolonging treatment.
HND06
! Optional Nutrition and Fluids Section (6 of 20)
!. STATEMENT OF DESIRES RELATIVE TO ARTIFICIALLY ADMINISTERED NUTRITION AND HYDRATION.
! Notwithstanding any provision of North Dakota law, it is my preference that the term "life-prolonging treatment" shall include artificially administered nutrition and hydration which only prolong the dying process and are not necessary to alleviate pain. Thus, in situations described in this document, it is my desire that I receive artificial nutrition or hydration only to the extent necessary to alleviate pain.
! [User to compose own statement.]
Enter an X to include a section concerning the Principal's desires regarding artificially administered nutrition and fluids. Press [Ctrl+F1] for more information.
Enter an X if the Principal desires to receive artificially administered nutrition and hydration as a treatment ONLY to alleviate pain and discomfort.
Enter an X if the Principal desires to compose a separate statement concerning the administration of artificial nutrition and hydration.
Use this space to state any other desires concerning artificial nutrition and hydration.
IGN06
! Optional Special Provisions Section (7 of 20)
!. 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 (8 of 20)
!. 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.
HND09
! Limits on Agent's Authority Section (9 of 20)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT:
This required section allows the Principal to establish limitations on the authority given to the Agent. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
Use this space to specify the limits 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. If there are none, type "None". Press [Ctrl+F1] for more information.
HND10
! Optional Anatomical Gifts Section (10 of 20)
!. If you wish to make a gift of any bodily organ you may do so pursuant to North Dakota Century Code chapter 23-06.2, the Uniform Anatomical Gift Act.
Enter an X to include a section which states the Agent has the authority to make anatomical gifts of any bodily organ pursuant to the North Dakota Century Code. Press [Ctrl+F1] for more information.
HND11
! Inspection and Disclosure of Information Section (11 of 20)
!. 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.
(If you want to limit the authority of your Agent to receive and disclose information relating to your health, you must state the limitations in paragraph 4 above.)
This required section enables the Agent to request, review, and disclose any information regarding the physical or mental condition of the Principal. Press [Ctrl+F1] for more information.
HND12
! Signing Documents, Waivers, and Releases Section (12 of 20)
!. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. 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, 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.
This required section gives the Agent the power to sign health care documents (such as admission, discharge, consent, or release forms) on behalf of the Principal. The Agent is NOT responsible for the cost of any medical service provided to the principal. Press [Ctrl+F1] for more information.
HND13
! Duration Section (13 of 20)
!. DURATION. Unless you specify a shorter period in the space below, this Durable Power of Attorney for Health Care will exist until it is revoked.
! [If you want your Agent's authority to end on a specific date.]
This Durable Power of Attorney for Health Care expires on !.
This required section states that unless an expiration date is specified, this power of attorney will exist until revoked. Press [Ctrl+F1] for more information.
Enter an X to include an expiration date for this power of attorney. If an expiration date is not specified, this document will remain in force until it is revoked or until the Principal's death. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the date this document will cease to be valid.
HND14
! Optional Designation of Alternate Agent Section (14 of 20)
!. DESIGNATION OF ALTERNATE AGENTS. If the person designated as my Agent in paragraph 1 is not available or becomes ineligible to act as my Agent to make a health care decision for me or loses the mental capacity to make health care decisions for me, or if I revoke that person's appointment or authority to act as my Agent to make health care decisions for me, then I designate and appoint the following persons to serve as my Agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below:
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 original Agent. Generally, the designation of the Principal's spouse as 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. The Alternate Agent must sign the printed document to indicate that he or she accepts this appointment and agrees to follow the Principal's wishes as stated in this document. Press [Ctrl+F1] for more information.
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.
IID13
! Revocation Section (15 of 20)
!. PRIOR DESIGNATIONS REVOKED. I revoke any prior Durable Power of Attorney for Health Care.
This required revocation section states that any prior Durable Power of Attorney for Health Care made by the Principal is revoked. Press [Ctrl+F1] for more information.
HND16
! Signature Section (16 of 20)
DATE AND SIGNATURE OF PRINCIPAL
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this Durable Power of Attorney for Health Care on the _____ day of _______________, 19___, at !, North Dakota.
__________________________________
Signature
Principal Name: !
Principal Address:City: !
County: ! County
State: !
! Country: !
! SSN: !
This section requires the signature of the Principal in the presence of two witnesses. If this procedure is not followed, the document may be invalid. Press [Ctrl+F1] for more information.
The program completes the city by transferring the information from a previous section. The program assumes you will sign the document in your city of residence. You can modify the information without affecting earlier data. This field may be left blank and be completed when the document is signed.
Enter the county or parish or edit the information. The other address information was transferred from a previous section and can be modified only by returning to that section.
Enter an X to include the Principal'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 Principal's social security number or edit the information as desired.
HND17
! Witness Signature Section (17 of 20)
(THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS POWER OF ATTORNEY.)
STATEMENT OF WITNESSES
This document must be witnessed by two qualified adult witnesses. None of the following may be used as a witness:
1. A person you designate as your Agent or Alternate Agent;
2. A health care provider;
3. An employee of a health care provider;
4. The operator of a long-term care facility;
5. An employee of an operator of a long-term care facility;
6. Your spouse;
7. A person related to you by blood or adoption;
8. A person entitled to inherit any part of your estate upon your death; or
9. A person who has, at the time of executing this document, any claim against your estate.
I declare under penalty of perjury that the person who signed or acknowledged this document is personally known to me to be the Principal, that the Principal signed or acknowledged this Durable Power of Attorney in my presence, that the Principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as Attorney-in-Fact by this document, and that I am not a health care provider; an employee of a health care provider; the operator of a long-term care facility; the Principal's spouse; a person related to the Principal by blood or adoption; a person entitled to inherit any part of the Principal's estate upon death; nor a person who has, at the time of executing this document, any claim against the Principal's estate.
This section requires the signature of two witnesses. By signing this document, the witnesses declare that they were present when the Principal 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 following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
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.
HND18
! Acceptance of Appointment Section (18 of 20)
[The Agent (and any Alternate Agents) must sign the document to indicate that they accept their appointment and they agree to follow the Principal's wishes as stated in the document.]
!. ACCEPTANCE OF APPOINTMENT OF POWER OF ATTORNEY. (To be effective, the Agent must accept the appointment in writing.) I accept this appointment and agree to serve as Agent for health care decisions. I understand I have a duty to act consistently with the desires of the Principal as expressed in this appointment. I understand that this document gives me authority over health care decisions for the Principal only if the Principal becomes incapable. I understand that I must act in good faith in exercising my authority under this power of attorney. I understand that the Principal may revoke this power of attorney at any time in any manner.
If I choose to withdraw during the time the Principal is competent I must notify the Principal of my decision. If I choose to withdraw when the Principal is incapable of making the Principal's health care decisions, I must notify the Principal's physician.
This required section states that the Agent agrees to act as the Principal's health care Agent, and to follow the Principal's wishes as stated in this document. Press [Ctrl+F1] for more information.
HND19
! Special Statement Section (19 of 20)
[Under the circumstances described below, this document is ineffective, unless the nature and effect of the document have been explained to the Principal by a designated person. It is recommended that a written acknowledgement also be signed as described below.]
SPECIAL STATEMENT
1. This Durable Power of Attorney for Health Care is NOT effective if, at the time of execution, the Principal is a resident of a long-term care facility. However, a recognized member of the clergy, an attorney licensed to practice in North Dakota, or a person designated by the Department of Human Services or the County court for the County in which the facility is located, may sign a statement affirming that the person has explained the nature and effect of the Durable Power of Attorney for Health Care to the Principal. Also, the Principal may acknowledge in writing that the Principal has read the warning prefacing this form which explains the nature and effect of a Durable Power of Attorney for Health Care.
2. A Durable Power of Attorney for Health Care is NOT effective if, at the time of execution, the Principal is being admitted to or is a patient in a hospital. However, a person designated by the hospital or an attorney licensed to practice in this state may sign a statement that the person has explained the nature and effect of the Durable Power of Attorney for Health Care to the Principal. Also, the Principal may acknowledge in writing that the Principal has read the warning prefacing this form which explains the nature and effect of a Durable Power of Attorney for Health Care.
This required section outlines the events which, if they occur, could make this document ineffective, unless the nature and effect of the document have been explained to the Principal by a member of the clergy, an attorney, or a person designated by the Department of Human Services or the County court.
DOM01
! Health Care Document Information Section (20 of 20)
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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