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.
This optional section states the Principal's wishes regarding life-sustaining procedures, artificial feeding, health care decisions and limits on the Agent's authority. 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 is an optional section which states that if the original Agent is not available, an Alternate Agent will assume responsibility of the original Agent. Press for more information.
This required section states that the Principal has read and understands the Disclosure Statement at the beginning of this document. Press [Ctrl+F1] for more information.
By signing this required section, the Principal acknowledges 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 and a Notary Public who acknowledge that the Principal signed the 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_NH
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becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures should be withheld or withdrawn under certain circumstances, and designates a person who will have authority to make health care decisions for the Principal, if the Principal is unable to do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 "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
HNH01
! Disclosure Statement Section (1 of 9)
INFORMATION CONCERNING THE DURABLE
POWER OF ATTORNEY FOR HEALTH CARE
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS:
Except to the extent you state otherwise, this document gives the person you name as your Agent the authority to make any and all health care decisions for you when you are no longer capable of making them yourself. "Health care" means any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition. Your Agent, therefore, can have the power to make a broad range of health care decisions for you. Your Agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. Your Agent cannot consent or direct any of the following: commitment to a state institution, sterilization, or termination of treatment if you are pregnant and if the withdrawal of that treatment is deemed likely to terminate the pregnancy unless the failure to withhold the treatment will be physically harmful to you or prolong severe pain which cannot be alleviated by medication.
You may state in this document any treatment you do not desire, except as stated above, or treatment you want to be sure you receive. Your Agent's authority will begin when your doctor certifies that you lack the capacity to make health care decisions. If for moral or religious reasons you do not wish to be treated by a doctor or examined by a doctor for the certification that you lack capacity, you must say so in the document and name a person to be able to certify your lack of capacity. That person may not be your Agent or Alternate Agent or any person ineligible to be your Agent. You may attach additional pages if you need more space to complete your statement.
If you want to give your Agent authority to withhold or withdraw the artificial providing of nutrition and fluids, your document must say so. Otherwise, your Agent will not be able to direct that. Under no conditions will your Agent be able to direct the withholding of food and drink for you to eat and drink normally.
Your Agent will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your Agent will have the same authority to make decisions about your health care as you would have had if made consistent with state law.
It is important that you discuss this document with your physician or other health care providers before you sign it to make sure that you understand the nature and range of decisions which may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.
The person you appoint as Agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your physician, or an employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your Agent or as your health or residential care provider; the law does not permit a person to do both at the same time.
You should inform the person you appoint that you want him or her to be your Health Care Agent. You should discuss this document with your Agent and your physician and give each a signed copy. You should indicate on the document itself the people and institutions who will have signed copies. Your Agent will not be liable for health care decisions made in good faith on your behalf.
Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your Agent by informing him or her or your health care provider orally or in writing.
This document may not be changed or modified. If you want to make changes in the document you must make an entirely new one.
You should consider designating an Alternate Agent in the event that your Agent is unwilling, unable, unavailable, or ineligible to act as your Agent. Any Alternate Agent you designate will have the same authority to make health care decisions for you.
THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO (2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN AND ACKNOWLEDGE YOUR SIGNATURE. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:
- the person you have designated as your Agent;
- your spouse;
- your lawful heirs or beneficiaries named in your will or a deed;
ONLY ONE OF THE TWO WITNESSES MAY BE YOUR HEALTH OR RESIDENTIAL CARE PROVIDER OR ONE OF THEIR EMPLOYEES.
This required section states that the Principal has been provided with a Disclosure Statement and that the information contained within the statement has been read and understood by the Principal. Press [Ctrl+F1] for more information.
HNH02
! Designation of Agent Section (2 of 9)
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
!. I, !, hereby appoint:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
as my Agent to make any and all health care decisions for me, except to the extent I state otherwise in this document or as prohibited by law. This Durable Power of Attorney for Health Care shall take effect in the event I become unable to make my own health care decisions.
RESTRICTIONS ON WHO MAY ACT AS AGENT
A person may not exercise the authority of Agent while serving in one of the following capacities:
1. The Principal's health care provider.
2. A nonrelative of the Principal who is an employee of the Principal's health care provider.
3. The Principal's residential care provider.
4. A nonrelative of the Principal who is an employee of the Principal's residential care provider.
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 name of the person who will be the Agent 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 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 can be reached during non-business hours.
Enter a phone number at which the Agent can be reached during business hours, if different from the home phone number.
Enter the relationship of the Agent to the Principal.
HNH03
! Optional Statement of Desires and Limitations Section (3 of 9)
STATEMENT OF DESIRES, SPECIAL PROVISIONS,
AND LIMITATIONS REGARDING HEALTH CARE DECISIONS
!. (Life-sustaining treatment is defined as procedures without which a person would die, such as but not limited to the following: cardiopulmonary resuscitation, mechanical respiration, kidney dialysis or the use of other external mechanical and technological devices, drugs to maintain blood pressure, blood transfusions and antibiotics.)
I give my Agent power to act in these specified circumstances. [Select any or all of the three following options or compose your own statement.]
! If I become permanently incompetent to make health care decisions, and if I am also suffering from a terminal illness, I authorize my Agent to direct that life-sustaining treatment be discontinued.
______________________________
Initials
(If this statement reflects your desires, you must initial the statement on the line provided.)
! Whether terminally ill or not, if I become permanently unconscious I authorize my Agent to direct that life-sustaining treatment be discontinued.
______________________________
Initials
(If this statement reflects your desires, you must initial the statement on the line provided.)
! I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial feeding (artificial nutrition and hydration). In carrying out any instructions I have given in this power of attorney, I authorize my Agent to direct that
! artificial nutrition and hydration not to be started or, if started, be discontinued.
! although all other forms of life-sustaining treatment be withdrawn, artificial nutrition and hydration continue to be given to me.
______________________________
Initials
(If this statement reflects your desires, you must initial the statement on the line provided.)
! [Optional provision - user may include specific desires or limitations on the Agent's authority, such as when or what life- sustaining treatment to be used or withheld, or instructions about refusing any specific types of treatment that are inconsistent with your religious beliefs or unacceptable to you for any other reason.]
Enter an X to include a section regarding the Principal's desires regarding life-sustaining treatment, artificial feeding, and other health care decisions. An optional provision allows the Principal to establish limits on the authority given to the Agent. Press [Ctrl+F1] for more information.
Enter an X if the Agent is authorized to direct the discontinuation of life-sustaining treatment in the event that the Principal is permanently incompetent and is suffering from a terminal illness.
Enter an X if the Agent is authorized to direct the discontinuation of life-sustaining treatment if the Principal is permanently unconscious with no hope of regaining awareness.
Enter an X to include a paragraph regarding artificially administered nutrition and hydration. Press [Ctrl+F1] for more information.
Enter an X if the Principal desires that artificial nutrition and hydration not be started or, if already started, be discontinued in the above circumstances.
Enter an X if the Principal desires that artificial nutrition and hydration be provided even though all other forms of treatment may be withdrawn.
Enter an X to include a section regarding specific desires concerning health care which are not otherwise contained in this document. For example, procedures desired or not desired, values or religious preferences, or limits on the Agent's authority. Press [Ctrl+F1] for more information.
Use this space to specify desires or limitations regarding health care.
IAL08
! Optional Inspection and Disclosure Information Section (4 of 9)
!. 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.
Enter an X to include a provision which 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.
HNH05
! Optional Designation of Alternate Agent Section (5 of 9)
!. In the event the person I appoint above is unable, unwilling or unavailable, or ineligible to act as my Health Care Agent, I hereby appoint the following persons as Alternate Agent:
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.
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.
HNH06
! Acknowledgement of Disclosure Statement Section (6 of 9)
!. I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this document. I have read and understand the information contained in the disclosure statement.
This required section states that the Principal has been provided, has read, and understands the disclosure statement presented at the beginning of the document. Press [Ctrl+F1] for more information.
HNH07
! Signature Section (7 of 9)
In witness whereof, I have hereunto signed my name this _____ day of _______________, 19___.
________________________________________
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 or a Notary Public. If this procedure is not followed, the document may be invalid. Press [Ctrl+F1] for more information.
Enter the Principal's city or edit the information as desired.
Enter the Principal's county/parish or edit the information as desired.
Enter the Principal's state/province or edit the pasted information as desired.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
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.
HNH08
! Witness/Notary Acknowledgement Section (8 of 9)
[This document must be signed by the Principal in the presence of two witnesses and a Notary Public.]
WITNESS SIGNATURE
I declare that the Principal appears to be of sound mind and free from duress at the time the Durable Power of Attorney for Health Care is signed and that the Principal has affirmed that he or she is aware of the nature of the document and is signing it freely and voluntarily.
The foregoing instrument was acknowledged before me this _____ day of _______________, 19___, by !.
My Commission Expires: _________________________
__________________________________
Notary Public/Justice of the Peace
This section requires the signature of two witnesses and a Notary Public. By signing this section, the witnesses declare that they were present when the Principal signed this document. 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.
DOM01
! Health Care Document Information Section (9 of 9)
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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