[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_NE18
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None of the following may serve as your Agent (Attorney-in-Fact):
(1) Your attending physician; (2) An employee of your attending physician who is not related to you by blood, marriage, or adoption; (3) A person not related to you by blood, marriage, or adoption who is an owner, operator, or employee of a health care provider in or of which you are a patient or resident; and (4) A person not related to you by blood, marriage, or adoption if, at the time of the proposed designation, he or she is personally serving as an Attorney-in-Fact for ten or more Principals.
3Who will be designated as Agent (Attorney-in-Fact)?
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.
HNE01019
Relation:#|
HCP_NE01
;What is the Agent's relationship, if any, to the Principal?
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Name: |
HCP_NE01
@Who is this Power of Attorney for Health Care being created for?
Enter the Principal's city or edit the information as desired.
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WITNESS STATEMENT: The Principal is personally known to us, and appears to be of sound mind and not under duress or undue influence. The Principal signed or acknowledged his or her signature on this document in our presence. Neither of us nor the Principal's attending physician is the person appointed as Attorney-in-Fact by this document. Nor are we the Principal's spouse, parent, child, grandchild, sibling, presumptive heir, known devisee at the time of witnessing, the attending physician, or an employee of a life or health insurance provider for the Principal. Not more than one of the witnesses is an administrator or employee of a health care provider who is caring for or treating the Principal.
HCP_NE17
HNE17002
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_NE17
2What are the names and addresses of the witnesses?
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HNE17002
WitnessesNotary
HCP_NE17
/Who will acknowledge the Principal's signature?
Enter an X if two witnesses will sign the document. Review the limits on who may be a witness which appear in the next question. Press [Ctrl+F1] for more information.
Enter an X if a Notary Public will be signing this document.
HNE17000
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Limitations:#|
HCP_NE07
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
Yes, the Agent will have access to information regarding the Principal's health.
HCP_NE08
>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 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_NE09
NWill the Agent have the power to sign health care documents for the Principal?
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HCP_NE03
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Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
HCP_NE04
MWhat are your desires concerning life-sustaining treatment and/or procedures?
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining procedures.
IGN04006
IGN04011
IGN04022
If I have an incurable conditionIf I am permanently unconsciousEither of the above
HCP_NE04
aUnder what circumstances should life-sustaining treatment or procedures be withheld or withdrawn?
Enter an X to withhold life-sustaining procedures if the condition of the Principal is incurable or irreversible and is expected to result in death within a relatively short time without such procedures.
Enter an X to withhold life-sustaining procedures if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-sustaining procedures if the Principal's condition is incurable and is expected to result in death within a relatively short time (without such procedures) or if the Principal is in a permanently unconscious state.
IGN04022
Specific desires:#|
HCP_NE04
VWhat are your specific desires concerning life-sustaining treatment and/or procedures?
IGN04022
Yes, include nutrition and fluids paragraph.
HCP_NE04
LDo you wish to state your desires regarding artificial nutrition and fluids?
IGN04023
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YesNo
HCP_NE04
Will artificially administered nutrition and fluids be included in the "life-sustaining procedures" that may be withheld or withdrawn?
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Yes, include life-sustaining procedures section.
HCP_NE04
GDo you wish to state your desires regarding life-sustaining procedures?
IGN04003
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Special provisions:#|
HCP_NE05
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_NE06
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.
=Who, if anyone, will be designated 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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IGN12027
Yes, include Alternate Agent section.
HCP_NE10
,Do you wish to designate an Alternate Agent?
IGN12003
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Agent (or Alternate)Other person
HCP_NE11
YWho do you nominate to be appointed as Guardian, if one is required by legal proceedings?
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