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 Attorney-in-fact. Press [Ctrl+F1] for more.
This section states that a Durable Power of Attorney is being created. It shall only 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 Attorney-in-fact is given. The Principal grants full power to the Attorney-in-fact to make health care decisions if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This required 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.
This is a required section which states this document will exist indefinitely unless otherwise specified. Press [Ctrl+F1] for more information.
This optional section states the Principal's wishes regarding life-sustaining procedures which artificially postpone death, and artificial nutrition and fluids. Press [Ctrl+F1] for more information.
This optional section states that if the original Attorney- in-fact is not available, an alternate Attorney-in-fact will assume responsibility of the original Attorney-in-fact. 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.
This required section states that any person or entity who faithfully carries out the terms and provisions of this document shall not be held liable for any damages which may occur. Press [Ctrl+F1] for more information.
This required section prevents the entire document from being invalidated if any provision of the document is declared invalid. Press [Ctrl+F1] for more information.
This required section states that this document be legally binding and if it is not recognized as a legal document it will be treated as a formal statement of the Principal's desires. 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 Attorney-in-fact. Press [Ctrl +F1] for more information.
This section requires the signature of two witnesses or a Notary Public to 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_NV
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.
HNV01
! Disclosure Statement Section (1 of 15)
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
WARNING TO PERSON EXECUTING THIS DOCUMENT:
THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF ATTORNEY FOR HEALTH CARE. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
1. THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR ATTORNEY-IN-FACT THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU. THIS POWER IS SUBJECT TO ANY LIMITATIONS OR STATEMENT OF YOUR DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE CONSENT, REFUSAL OF CONSENT, OR WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT YOU DO NOT DESIRE.
2. THE PERSON YOU DESIGNATE IN THIS DOCUMENT HAS A DUTY TO ACT CONSISTENT WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN OR, IF YOUR DESIRES ARE UNKNOWN, TO ACT IN YOUR BEST INTERESTS.
3. EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THE POWER OF THE PERSON YOU DESIGNATE TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE THE POWER TO CONSENT TO YOUR DOCTOR NOT GIVING TREATMENT OR STOPPING TREATMENT WHICH WOULD KEEP YOU ALIVE.
4. UNLESS YOU SPECIFY A SHORTER PERIOD IN THIS DOCUMENT, THIS POWER WILL EXIST INDEFINITELY FROM THE DATE YOU EXECUTE THIS DOCUMENT AND, IF YOU ARE UNABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF, THIS POWER WILL CONTINUE TO EXIST UNTIL THE TIME WHEN YOU BECOME ABLE TO MAKE HEALTH CARE DECISIONS FOR YOURSELF.
5. 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. IN ADDITION, NO TREATMENT MAY BE GIVEN TO YOU OVER YOUR OBJECTION, AND HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY NOT BE STOPPED IF YOU OBJECT.
6. YOU HAVE THE RIGHT TO REVOKE THE APPOINTMENT OF THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THAT PERSON OF THE REVOCATION ORALLY OR IN WRITING.
7. YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY GRANTED TO THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THE TREATING PHYSICIAN, HOSPITAL, OR OTHER PROVIDER OF HEALTH CARE ORALLY OR IN WRITING.
8. THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT.
9. THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF ATTORNEY FOR HEALTH CARE.
10. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.
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 "Attorney-in-Fact").
HNV02
! Designation of Agent Section (2 of 15)
!. DESIGNATION OF HEALTH CARE AGENT.
I, !, do hereby designate and appoint:
Agent: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
as my Attorney-in-Fact ("Agent") to make health care decisions for me as authorized in this document.
NOTE: Unless the person is also your spouse, legal guardian or related to you by blood, none of the following may be designated as your Attorney-in-Fact: (1) your treating provider of health care, (2) an employee of your treating provider of health care, (3) an operator of a health care facility, or (4) an employee of an operator of a health care facility.
This required section states the name and address of the person appointed as Attorney-in-Fact (Health Care Agent). The Attorney-in-Fact 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 Attorney-in-Fact (Agent) or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Attorney-in-Fact. The Attorney-in-Fact will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
Enter the Attorney-in-Fact's street address or edit the information as desired.
Enter the Attorney-in-Fact's extended street address or edit the information as desired.
Enter the Attorney-in-Fact's city or edit the information as desired.
Enter the Attorney-in-Fact's state/province or edit the information as desired. When naming an Attorney-in-Fact, consider the availability of the Attorney-in-Fact to confer with health care providers and access medical records and information.
Enter the Attorney-in-Fact's zip/postal code or edit the information as desired.
Enter an X to include the Attorney-in-Fact's country. If the Attorney-in-Fact 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 Attorney-in-Fact may be reached during non-business hours.
Enter a phone number at which the Attorney-in-Fact may be reached during business hours, if different from the home phone number.
Enter the relationship of the Attorney-in-Fact to the Principal.
HNV03
! Creation of Health Care Power of Attorney Section (3 of 15)
!. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney by appointing the person designated above to make health care decisions for me. This power of attorney shall not be affected by my subsequent incapacity.
This required section states that a Durable Power of Attorney for Health Care is being created. It shall only be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more information.
HNV04
! Attorney-In-Fact's Authority Section (4 of 15)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. In the event that I am incapable of giving informed consent with respect to health care decisions, I hereby grant to the Attorney-in-Fact named above full power and authority to make health care decisions for me before, or after my death, including: consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition, subject only to the limitations and special provisions, if any, set forth in paragraph 4 or 6.
This required section states the general duties and powers of the Attorney-in-Fact on behalf of the Principal. The health care decisions made by the Attorney-in-Fact must be consistent with the desires of the Principal as stated in this document, or otherwise known to the Attorney-in-Fact.
HNV05
! Special Provisions Section (5 of 15)
!. SPECIAL PROVISIONS AND LIMITATIONS. (Your Attorney-in-Fact is not permitted to consent to any of the following: commitment to or placement in a mental health treatment facility, convulsive treatment, psychosurgery, sterilization, or abortion. If there are any other types of treatment or placement that you do not want your Attorney-in- Fact's authority to give consent for or other restrictions you wish to place on his or her Attorney-in-Fact's authority, you should list them in the space below. If you do not write any limitations, your Attorney-in-Fact will have the broad powers to make health care decisions on your behalf which are set forth in paragraph 3, except to the extent that there are limits provided by law.)
In exercising the authority under this Durable Power of Attorney for Health Care, the authority of my Attorney-in-Fact is subject to the following special provisions and limitations: !
This required section enables the Principal to establish limitations on the authority given to the Attorney-in-Fact. For example, the Principal may prohibit the Attorney-in-Fact from authorizing certain procedures. The Principal may also state special provisions regarding health care. Press [Ctrl+F1] for more information.
Use this space to specify limitations on the authority of the Attorney-in-Fact to make decisions on behalf of the Principal, or other special provisions not otherwise contained in this document. Press [Ctrl+F1] for more information.
HNV06
! Duration Section (6 of 15)
!. DURATION. I understand that this power of attorney will exist indefinitely from the date I execute this document unless I establish a shorter time. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my Attorney-in-Fact will continue to exist until the time when I become able to make health care decisions for myself.
! [Select this option if you want the power of attorney to end on a specific date.]
I wish to have this power of attorney end on the following date: !.
This required section states that the power of attorney will exist indefinitely unless otherwise stated within the document. Press [Ctrl+F1] for more information.
Enter an X to include the date on which this power of attorney will cease to be effective. 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, specify the date the document will cease to be effective.
HNV07
! Optional Statement of Desires Section (7 of 15)
!. STATEMENT OF DESIRES. (With respect to decisions to withhold or withdraw life-sustaining treatment, your Attorney-in-Fact must make health care decisions that are consistent with your known desires. You can, but are not required to, indicate your desires below. If your desires are unknown, your Attorney-in-Fact has the duty to act in your best interests; and, under some circumstances, a judicial proceeding may be necessary so that a court can determine the health care decision that is in your best interests. If you wish to indicate your desires, you may INITIAL the statement or statements that reflect your desires and/or compose your own statements.)
(If the statement reflects your desires, initial the line below the statement.)
! I desire that my life be prolonged to the greatest extent possible, without regard to my condition, the chances I have for recovery or long-term survival, or the cost of the procedures.
_______________
(Initials)
! If I am in a coma which my doctors have reasonably concluded is irreversible, I desire that life-sustaining or prolonging treatments not be used. (Also should utilize provisions of NRS 449.540 to 449.690, inclusive, (Uniform Act on Rights of the Terminally Ill) if this subparagraph is initialed.)
_______________
(Initials)
! If I have an incurable or terminal condition or illness and no reasonable hope of long-term recovery or survival, I desire that life-sustaining or prolonging treatments not be used. (Also should utilize provisions of NRS 449.540 to 449.690, inclusive, (Uniform Act on Rights of the Terminally Ill) if this subparagraph is initialed.)
_______________
(Initials)
! Withholding or withdrawal of artificial nutrition and hydration may result in death by starvation or dehydration. I want to receive or continue receiving artificial nutrition and hydration by way of the gastro-intestinal tract after all other treatment is withheld.
_______________
(Initials)
! I do not desire treatment to be provided and/or continued if the burdens of the treatment outweigh the expected benefits. My Attorney-in-Fact is to consider the relief of suffering, the preservation or restoration of functioning, and the quality as well as the extent of the possible extension of my life.
_______________
(Initials)
! [Compose your own statement of desires.] !
_______________
(Initials)
Enter an X to include a section concerning the Principal's desires regarding life-sustaining 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 Principal desires every possible treatment to prolong his/her life to the greatest extent, regardless of cost or chances for recovery.
Enter an X to withdraw or withhold all life-sustaining treatment if the Principal is in a permanently unconscious condition and there is no reasonable expectation of recovery by the Principal.
Enter an X if the Principal wishes that any life-sustaining treatment be withheld or withdrawn if the Principal's condition is incurable or there is no hope for survival.
Enter an X if the Principal does not want the physician to withhold or withdraw any artificial nutrition or hydration. Press [Ctrl+F1] for more information.
Enter an X if the Principal gives the Attorney-in-Fact the discretion to decide if and when life-sustaining treatment may be withdrawn or withheld. The Attorney-in-Fact will decide if the burdens of the treatment outweigh the benefits.
Enter an X if the Principal desires to compose a paragraph regarding additional desires concerning life-sustaining treatment. Any of the above statements may be edited or additional statements may be composed.
Use this space to compose a paragraph describing additional desires concerning treatment.
HNV08
! Optional Designation of Alternate Attorney-In-Fact Section (8 of 15)
!. DESIGNATION OF ALTERNATE ATTORNEY-IN-FACT. (You are not required to designate any Alternate Attorney-in-Fact but you may do so. Any Alternate Attorney-in-Fact you designate will be able to make the same health care decisions as the Attorney-in-Fact designated in paragraph 1, page 2, in the event that he or she is unable or unwilling to act as your Attorney-in-Fact. Also, if the Attorney-in- Fact designated in paragraph 1 is your spouse, his or her designation as your Attorney-in-Fact is automatically revoked by law if your marriage is dissolved.)
If the person designated in paragraph 1 as my Attorney-in-Fact is unable to make health care decisions for me, then I designate the following persons to serve as my Attorney-in-Fact to make health care decisions for me as authorized in this document, such persons to serve in the order listed below:
FIRST ALTERNATE ATTORNEY-IN-FACT
Attorney-in-Fact: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
SECOND ALTERNATE ATTORNEY-IN-FACT
Attorney-in-Fact: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Enter an X to designate an Alternate Attorney-in-Fact. If the original Attorney-in-Fact resigns or is unable to perform, an Alternate will assume all responsibilities of the original Attorney-in-Fact. Generally, the designation of the Principal's spouse as Attorney-in-Fact is revoked upon divorce.
Enter the Alternate Attorney-in-Fact's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Attorney-in-Fact's street address or edit the information as desired.
Enter the Alternate Attorney-in-Fact's extended street address or edit the information as desired.
Enter the Alternate Attorney-in-Fact's city or edit the information as desired.
Enter the Alternate Attorney-in-Fact's state/province or edit the information as desired. When naming an Alternate Attorney-in-Fact, consider the availability of the Alternate Attorney-in-Fact to confer with health care providers.
Enter the Alternate Attorney-in-Fact's zip/postal code or edit the information as desired.
Enter an X to include the Alternate Attorney-in-Fact's country. If the Alternate Attorney-in-Fact resides in a different country, consider the availability of the Alternate Attorney-in-Fact 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 Attorney-in-Fact may be reached during non-business hours.
Enter a phone number at which the Alternate Attorney-in-Fact 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.
Enter the second Alternate Attorney-in-Fact's name or use the P.I. Manager to select and paste a record.
IID13
! Revocation Section (9 of 15)
!. 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.
IGN16
! Hold Harmless Section (10 of 15)
!. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
This is a required section in which the Principal states that the Agent and anyone who relies upon any representation by the Agent shall not be liable to the Principal or any interests involved with the Principal. Press [Ctrl+F1] for more information.
IGN17
! Severability Section (11 of 15)
!. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
This required section prevents the entire document from being invalidated if any provision of the document is declared invalid. Press [Ctrl+F1] for more information.
IGN18
! Statement of Intentions Section (12 of 15)
!. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
This required section is a statement of the Principal's desire that the document be legally recognized either as a legal document or a formal statement of the Principal's wishes and desires regarding health care decisions. Press [Ctrl+F1] for more information.
HNV13
! Signature Section (13 of 15)
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this Durable Power of Attorney for Health Care on this _____ day of _______________, 19___, at _________________________, Nevada.
(THIS POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH CARE DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO QUALIFIED WITNESSES WHO ARE PERSONALLY KNOWN TO YOU AND WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.)
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. The Principal's name was transferred from a previous section and can be modified only by returning to that section.
Enter the Principal's county/parish or edit the information as desired.
Enter the Principal's state/province or edit the 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 as desired.
HNV14
! Notary/Witness Acknowledgement Section (14 of 15)
! [WITNESS BLOCK]
STATEMENT OF WITNESSES
(You should carefully read and follow this witnessing procedure. This document will not be valid unless you comply with the witnessing procedure. If you elect to use witnesses instead of having this document notarized you must use two qualified adult witnesses. None of the following may be used as a witness: (1) a person you designate as the Attorney-in-Fact, (2) a provider of health care, (3) an employee of a provider of health care, (4) the operator of a health care facility, (5) an employee of an operator of a health care facility. At least one of the witnesses must make the additional declaration set out following the place where the witnesses sign.)
I declare under penalty of perjury that the Principal is personally known to me, 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 provider of health care, an employee of a provider of health care, the operator of a community care facility, nor an employee of an operator of a health care facility.
(AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.)
I declare under penalty of perjury that I am not related to the Principal by blood, marriage, or adoption, and to the best of my knowledge I am not entitled to any part of the estate of the Principal upon the death of the Principal under a will now existing or by operation of law.
(You may use acknowledgement before a Notary Public instead of the statement of witnesses.)
STATE OF NEVADA )
) ss:
COUNTY OF _________________________ )
On this _____ day of _______________, 19___, before me, _______________________________ personally appeared, !, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it. I declare under penalty of perjury that the person whose name is ascribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence.
COPIES: You should retain an executed copy of this document and give one to your Attorney-in-Fact. The power of attorney should be available so a copy may be given to your providers of health care.
This document requires the signatures of two witnesses or a Notary Public. By signing this section, the persons declare that they were present when the Principal signed this document. Note the limits on who may serve as witnesses. Press [Ctrl+F1] for more information.
Enter an X if two witnesses will be signing the document. Read the following paragraphs and complete the fields at the end. If the document is not properly witnessed, it may not be enforceable. 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.
Enter an X if a Notary Public will be signing the document. The Principal's name was transferred from a previous section and can be modified only by returning to that section.
DOM01
! Health Care Document Information Section (15 of 15)
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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