This required section contains a statement about the use of this document under Ohio law. This information will print as the first pages of the document and should be read before the document is signed. Press [Ctrl+F1] for more.
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 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 treatment 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 treatment provided. 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 [Ctrl+F1] for more information.
This is a required section which states this document becomes effective upon a physician's determination that the Principal is unable to make informed health care decisions. 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 Agent. Press [Ctrl+F1] for more information.
This section requires the signature of two witnesses or the signature of 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_OH
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.
Enter the Principal's city 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.
HOH01
(! Disclosure Statement Section (1 of 14)
[This section contains a Disclosure Statement which is required by Ohio law. The statement explains the purpose and consequences of this Durable Power of Attorney for Health Care. There are no entry fields to complete on this screen. You must read this statement, either now or after the document is printed, before you sign the document.]
NOTICE TO ADULT EXECUTING THIS DOCUMENT
This is an important legal document. Before executing this document, you should know these facts:
This document gives the person you designate (the Attorney-in-Fact) the power to make MOST health care decisions for you if you lose the capacity to make informed health care decisions for yourself. This power is effective only when your attending physician determines that you have lost the capacity to make informed health care decisions for yourself and, notwithstanding this document, as long as you have the capacity to make informed health care decisions for yourself, you retain the right to make all medical and other health care decisions for yourself.
You may include specific limitations in this document on the authority of the Attorney-in-Fact to make health care decisions for you.
Subject to any specific limitations you include in this document, if your attending physician determines that you have lost the capacity to make an informed decision on a health care matter, the Attorney-in- Fact GENERALLY will be authorized by this document to make health care decisions for you to the same extent as you could make those decisions yourself, if you had the capacity to do so. The authority of the Attorney-in-Fact to make health care decisions for you GENERALLY will include the authority to give informed consent, to refuse to give informed consent, or to withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
HOWEVER, even if the Attorney-in-Fact has general authority to make health care decisions for you under this document, the Attorney-in- Fact NEVER will be authorized to do any of the following:
(1) Refuse or withdraw informed consent to life-sustaining treatment (unless your attending physician and one other physician who examines you determine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that either of the following applies:
(a) You are suffering from an irreversible, incurable and untreatable condition caused by disease, illness, or injury from which (i) there can be no recovery and (ii) your death is likely to occur within a relatively short time if life-sustaining treatment is not administered, and your attending physician additionally determines, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that there is no reasonable possibility that you will regain the capacity to make informed health care decisions for yourself.
(b) You are in a state of permanent unconsciousness that is characterized by you being irreversibly unaware of yourself and your environment and by a total loss of cerebral cortical functioning, resulting in you having no capacity to experience pain or suffering, and your attending physician additionally determines, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that there is no reasonable possibility that you will regain the capacity to make informed health care decisions for yourself);
(2) Refuse or withdraw informed consent to health care necessary to provide you with comfort care (except that, if he is not prohibited from doing so under (4) below, the Attorney-in-Fact could refuse or withdraw informed consent to the provision of nutrition or hydration to you as described under (4) below). (YOU SHOULD UNDERSTAND THAT COMFORT CARE IS DEFINED IN OHIO LAW TO MEAN ARTIFICIALLY OR TECHNOLOGICALLY ADMINISTERED SUSTENANCE (NUTRITION) OR FLUIDS (HYDRATION) WHEN ADMINISTERED TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH, AND ANY OTHER MEDICAL OR NURSING PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE THAT WOULD BE TAKEN TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH. CONSEQUENTLY, IF YOUR ATTENDING PHYSICIAN WERE TO DETERMINE THAT A PREVIOUSLY DESCRIBED MEDICAL OR NURSING PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN, THEN, SUBJECT TO (4) BELOW, YOUR ATTORNEY-IN-FACT WOULD BE AUTHORIZED TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE.);
(3) Refuse or withdraw informed consent to health care for you if you are pregnant and if the refusal or withdrawal would terminate the pregnancy (unless the pregnancy or health care would pose a substantial risk to your life, or unless your attending physician and at least one other physician who examines you determine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that the fetus would not be born alive);
(4) REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY ADMINISTERED SUSTENANCE (NUTRITION) OR FLUIDS (HYDRATION) TO YOU, UNLESS:
(a) YOU ARE IN A TERMINAL CONDITION OR IN A PERMANENTLY UNCONSCIOUS STATE.
(b) YOUR ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED YOU DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN.
(c) IF, BUT ONLY IF, YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE, YOU AUTHORIZE THE ATTORNEY-IN-FACT TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION TO YOU BY DOING BOTH OF THE FOLLOWING IN THIS DOCUMENT:
(i) INCLUDING A STATEMENT IN CAPITAL LETTERS THAT THE ATTORNEY-IN-FACT MAY REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION TO YOU IF YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE AND IF THE DETERMINATION THAT NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN IS MADE, OR CHECKING OR OTHERWISE MARKING A BOX OR LINE (IF ANY) THAT IS ADJACENT TO A SIMILAR STATEMENT ON THIS DOCUMENT;
(ii) PLACING YOUR INITIALS OR SIGNATURE UNDERNEATH OR ADJACENT TO THE STATEMENT, CHECK, OR OTHER MARK PREVIOUSLY DESCRIBED.
(d) YOUR ATTENDING PHYSICIAN DETERMINES, IN GOOD FAITH, THAT YOU AUTHORIZED THE ATTORNEY-IN-FACT TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION TO YOU IF YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE BY COMPLYING WITH THE REQUIREMENTS OF (4)(c)(i) AND (ii) ABOVE.
(5) Withdraw informed consent to any health care to which you previously consented, unless a change in your physical condition has significantly decreased the benefit of that health care to you, or unless the health care is not, or is no longer, significantly effective in achieving the purposes for which you consented to its use.
Additionally, when exercising his authority to make health care decisions for you, the Attorney-in-Fact will have to act consistently with your desires or, if your desires are unknown, to act in your best interest. You may express your desires to the Attorney-in-Fact by including them in this document or by making them known to him in another manner.
When acting pursuant to this document, the Attorney-in-Fact GENERALLY will have the same rights that you have to receive information about proposed health care, to review health care records, and to consent to the disclosure of health care records. You can limit that right in this document if you so choose.
Generally, you may designate any competent adult as the Attorney-in-Fact under this document. However. you CANNOT designate your attending physician or the administrator of any nursing home in which you are receiving care as the Attorney-in-Fact under this document. Additionally, you CANNOT designate an employee or agent of your attending physician, or an employee or agent of a health care facility at which you are being treated, as the Attorney-in-Fact under this document, unless either type of employee or agent is a competent adult and related to you by blood, marriage, or adoption, or unless either type of employee or agent is a competent adult and you and the employee or agent are members of the same religious order.
This document has no expiration date under Ohio law, but you may choose to specify a date upon which your Durable Power of Attorney for Health Care generally will expire. However, if you specify an expiration date and then lack the capacity to make informed health care decisions for yourself on that date, the document and the power it grants to your Attorney-in-Fact will continue in effect until you regain the capacity to make informed health care decisions for yourself.
You have the right to revoke the designation of the Attorney-in-Fact and the right to revoke this entire document at any time and in any manner. Any such revocation generally will be effective when you express your intention to make the revocation. However, if you made your attending physician aware of this document, any such revocation will be effective only when you communicate it to your attending physician, or when a witness to the revocation or other health care personnel to whom the revocation is communicated by such a witness communicate it to your attending physician.
If you execute this document and create a valid Durable Power of Attorney for Health Care with it, it will revoke any prior, valid Durable Power of Attorney for Health Care that you created, unless you indicate otherwise in this document.
This document is not valid as a Durable Power of Attorney for Health Care unless it is acknowledged before a Notary Public or is signed by at least two adult witnesses who are present when you sign or acknowledge your signature. No person who is related to you by blood, marriage, or adoption may be a witness. The Attorney-in-Fact, your attending physician, and the administrator of any nursing home in which you are receiving care also are ineligible to be witnesses.
If there is anything in this document that you do not understand, you should ask your lawyer to explain it to you.
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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 ("Principal") and the person appointed to make health care decisions ("Agent").
HOH02
! Designation of Health Care Agent Section (2 of 14)
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
!. DESIGNATION OF HEALTH CARE AGENT.
I, !, of !, !,
! Country: !,
being of sound mind and not subject to duress, fraud or undue influence, intend to create a 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: !
to be my health care Agent (Attorney-in-Fact) to make health care decisions for me as authorized in this document.
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 city 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 the Agent's name or use the P.I. Manager to select and paste a record.
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 a phone number at which the Agent may 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.
HOH03
! Authority of Agent Section (3 of 14)
!. 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 have the authority to give, to withdraw or to refuse to give informed consent to any medical or nursing procedure, treatment, intervention or other measure used to maintain, diagnose or treat my physical or mental condition. 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, or if I have not made my desires known, my Agent shall act in my best interests.
This is a required section which 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.
HOH04
! Additional Instructions Section (4 of 14)
!. ADDITIONAL INSTRUCTIONS. Subject to any limitations in this document, my health care Agent has the power and authority to do all of the following:
a. If I am in a terminal condition, to refuse or withdraw informed consent to life-sustaining treatment
! , including the provision of artificially or technologically administered hydration and nutrition
b. If I am in a permanently unconscious state, to withdraw or to refuse to give informed consent to life-sustaining treatment. My agent is not authorized to refuse or direct the withdrawal of artificially or technologically administered nutrition or hydration unless I have specifically authorized such withdrawal or withholding in paragraph 4 of this document;
c. To request, review and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records;
d. To execute on my behalf any releases or other documents that may be required in order to obtain this information;
e. To consent to the disclosure of this information;
f. To select, employ, and discharge health care professionals;
g. To select and contract with any medical or health care facility on my behalf;
h. 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:
(1) Written consent to medical treatment, DO NOT RESUSCITATE orders, or similar documents;
(2) Documents requesting a transfer to another facility, or a request to leave a medical facility against medical advise, or similar request; and
(3) Any necessary waiver or release from liability required by a hospital or physician.
Enter an X to include a section which describes the Agent's authority under Ohio law. For example, the authority to consent to the withdrawal or withholding of life-sustaining treatment, review medical records, and sign releases. Press [Ctrl+F1] for more information.
Enter an X if the Agent has the authority to refuse or withdraw artificially administered nutrition or hydration if the Principal has a terminal condition.
HOH05
! Optional Nutrition and Fluids Section (5 of 14)
!. WITHDRAWAL OF NUTRITION AND HYDRATION WHEN IN A PERMANENTLY UNCONSCIOUS STATE. [If this provision is selected, you will need to initial it on the printed document.]
[X] __________ (Initials) IF I HAVE PLACED MY INITIALS ON THE LINE ADJACENT TO THIS PROVISION, MY AGENT MAY REFUSE, OR IN THE EVENT TREATMENT HAS ALREADY COMMENCED, WITHDRAW INFORMED CONSENT TO THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIED NUTRITION AND HYDRATION IF I AM IN A PERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN.
Enter an X if the Agent will be authorized to withhold or withdraw artificial nutrition and hydration if the Principal is in a permanently unconscious state. Press [Ctrl+F1] for more information.
HOH06
! Designation of Alternate Agent Section (6 of 14)
!. DESIGNATION OF ALTERNATE AGENT. If any Agent named by me shall die, become incompetent, resign, refuse to accept the office of Agent or be unavailable, I name the following (each to act alone and successively, in the order named) as Successors to such Agent.
FIRST ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relationship (if any): !
SECOND ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relationship (if any): !
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 the relationship of the Alternate Agent to the Principal.
Enter an X to include the name of a second Alternate Agent. You do not have to name a second Alternate Agent.
HOH07
! Duration Section (7 of 14)
!. DURATION. This power is effective only when my attending physician determines that I have lost the capacity to make informed health care decisions. This Durable Power of Attorney for Health Care shall not be affected by my disability or by lapse of time, and shall continue indefinitely or until it is revoked.
This required section states this document will be effective once a physician determines the Principal is incapable of making informed health care decisions. The Agent's power to make health care decisions shall remain effective as long as the Principal is unable to make such decisions. Press [Ctrl+F1] for more information.
IID13
! Revocation Section (9 of 14)
!. 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 (9 of 14)
!. 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 (10 of 14)
!. 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 (11 of 14)
!. 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.
HOH12
! Signature Section (12 of 14)
By my signature I indicate that I understand the purpose and effect of this document, after careful reflection, while I am of sound mind, I execute this Durable Power of Attorney for Health Care on the _____ day of _______________, 19___.
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 county/parish or edit the information as desired. 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.
HOH13
! Witness/Notary Statement Section (13 of 14)
! [WITNESS BLOCK]
STATEMENT OF WITNESSES
The undersigned witnesses attest that the Principal signed or acknowledged this Durable Power of Attorney for Health Care in our presence and it is our belief that the Principal appears to be of sound mind and not under or subject to duress, fraud or undue influence. We are not the agent designated in this document. Furthermore, we are adults not related to the Principal by blood, marriage or adoption, are not the attending physician of the Principal, and are not the administrator of any nursing home in which the Principal is receiving care.
On this the _____ day of _______________, 19___, before me, the undersigned Notary Public, personally appeared ______________________, known to me or satisfactorily proven to be the person whose name is subscribed to the above Durable Power of Attorney for Health Care as the Principal, and acknowledged that (s)he executed the same for the purposes expressed therein. I attest that the Principal appears to be of sound mind and not under or subject to duress, fraud or undue influence.
My Commission Expires: __________________
________________________________________
Notary Public
This section requires the signature of two witnesses or a Notary Public. By signing this section, the witnesses or the Notary declare that they were present when the Principal signed this document. Note the limits on who may serve as witness. Press [Ctrl+F1] for more information.
Enter an X if two witnesses will be signing this document. 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 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 this document. Press [Ctrl+F1] for more information.
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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