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 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 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 required 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 required 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 that this document will exist indefinitely unless otherwise specified. Press [Ctrl+F1] for more information.
This required section states that if the original Agent is not available, an alternate Agent will assume the responsibilities 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 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_RI
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.
HRI01
! Disclosure Statement Section (1 of 13)
STATUTORY FORM
DURABLE POWER OF ATTORNEY
FOR HEALTH CARE
WARNING TO PERSON EXECUTING THIS DOCUMENT
This is an important legal document which 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 (18) years of age and a resident of the state of Rhode Island 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. In addition, no treatment may be given to you over your objection at the time, and health care necessary to keep you alive may not be stopped or withheld if you object at the time.
This document gives your Agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. 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:
(1) Authorizes anything that is illegal,
(2) Acts contrary to your known desires, or
(3) Where your desires are not known, does anything that is clearly contrary to your best interests.
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 or give each of them an executed copy of this document. You may also want to 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").
HRI02
! Designation of Health Care Agent Section (2 of 13)
!. 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: !
(Insert the name and address of one individual only as your Agent to make health care decisions for you. 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 or mental 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 or edit the information as desired. In most cases, the Principal's state will be Rhode Island.
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 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 discuss medical decisions with the health care providers.
Enter a phone number where the Agent can be reached during non-business hours.
Enter a phone number where the Agent can 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 13)
!. 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.
HRI04
! Agent's Authority Section (4 of 13)
!. 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, but not limited to, 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 ("Statement of Desires, Special Provisions, and Limitations") below. You can indicate your desires by including a statement of your desires in the same paragraph.)
This required section outlines 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.
HRI05
! Statement of Desires, Special Provisions, and Limitations Section (5 of 13)
!. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. (Your Agent must make health care decisions that are consistent with your known desires. You can, but are not required to, state your desires in the space provided below. You should consider whether you want to include a statement of your desires concerning life-prolonging care, treatment, services, and procedures. You can also include a statement of your desires concerning other matters relating to your health care. You can also make your desires known to your Agent by discussing your desires with your Agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit in any other way the authority given your Agent by this document, you should state the limits in the space below. If you do not state any limits, your Agent will have broad powers to make health care decisions for you, except to the extent that there are limits provided by law.)
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:
a. Statement of desires concerning life-prolonging care, treatment, services, and procedures: !
[Optional statement of desires relative to artificially administered nutrition and hydration:]
! My Agent's authority
! includes
! does not include
the withholding or withdrawal of artificial feeding (artificially administered nutrition and hydration), except as for my comfort, or to alleviate pain.
! [Compose your own statement.]
b. Additional statement of desires, special provisions, and limitations regarding health care decisions:
(You may attach additional pages if you need more space to complete your statement. If you attach additional pages, you must date and sign EACH of the additional pages at the same time you date and sign this document.) If you wish to make a gift of any bodily organ you may do so pursuant to the Uniform Anatomical Gift Act.
This required section enables the Principal to specify any special provisions or desires concerning health care. The Agent will make decisions based on the desires of the Principal. Press [Ctrl+F1] for more information.
Use this space to include any desires concerning life-prolonging care, treatment, services, or procedures. Press [Ctrl+F1] for sample provisions.
Enter an X to include a section concerning the Agent's authority to withhold or withdraw artificial feeding.
Enter an X if the Agent's authority DOES include the withholding or withdrawal of artificial feeding.
Enter an X if the Agent's authority DOES NOT include the withholding or withdrawal of artificial feeding.
Enter an X if the Principal wishes to compose a separate statement of desires concerning special provisions.
Use this space to include special provisions. For example, specify any types of treatment desired or not desired. You may also describe values or religious preferences, or the location of treatment. Press [Ctrl+F1] for more information.
Use this space to include additional special provisions or desires.
HRI06
! Inspection and Disclosure of Information Section (6 of 13)
!. 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 do all of the following:
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. Execute on my behalf any releases or other documents that may be required in order to obtain this information;
c. Consent to the disclosure of this information.
(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, "Statement of Desires, Special Provisions, and Limitations", 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.
HRI07
! Signing Documents, Waivers and Releases Section (7 of 13)
!. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to implement the health care decisions that my Agent is authorized by this document to make, my Agent has the power and authority to execute on my behalf all of the following:
a. Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice";
b. 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.
HRI08
! Duration Section (8 of 13)
!. DURATION. (Unless you specify a shorter period in the space below, this power of attorney will exist until it is revoked.)
This Durable Power of Attorney for Health Care expires on !. (Fill in this space ONLY if you want the authority of your Agent to end on a specific date.)
This required section states that this document will exist indefinitely unless a specific date is established. Press [Ctrl+F1] for more information.
Enter an X to include a specific date on which the document will cease to be effective. If an expiration date is not specified, the 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.
HRI09
! Designation of Alternate Agent Section (9 of 13)
!. DESIGNATION OF ALTERNATE AGENTS. (You are not required to designate any Alternate Agents but you may do so. Any Alternate Agent you designate will be able to make the same health care decisions as the Agent you designated in paragraph 1, above, in the event that Agent is unable or ineligible to act as your Agent. If the Agent you designated is your spouse, he or she becomes ineligible to act as your Agent if your marriage is dissolved.)
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: !
This required section allows the Principal to designate an Alternate Agent. If the original Agent resigns or is unable to perform, an Alternate 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. If the Agent resigns or is unable to perform, the Alternate Agent will assume the responsiblities of the 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 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 the Alternate Agent's country. If the Alternate Agent resides in a different country, consider the availability of the Alternate 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 hours.
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.
Enter the Alternate Agent's name or use the P.I. Manager to select and paste a record.
IID13
! Revocation Section (10 of 13)
!. 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.
HRI11
! Signature Section (11 of 13)
DATE AND SIGNATURE OF PRINCIPAL
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this Statutory Form Durable Power of Attorney for Health Care on the _____ day of _______________, 19___, at !, Rhode Island.
________________________________________
(You sign here)
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, assuming the Principal will sign the document in his or her city of residence. You can modify the information without affecting earlier data or you may leave this field blank and fill in the information at the time the document is signed.
HRI12
! Witness Signature Section (12 of 13)
(THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED BY TWO (2) 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 (2) 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 community care facility;
5. An employee of an operator of a community 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 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 community care facility; nor an employee of an operator of a community care facility.
(AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.)
I further 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.
This section requires the signatures of two witnesses. By signing this section, 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 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 (13 of 13)
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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