[THIS SECTION IS FOR YOUR INFORMATION ONLY. IT WILL NOT BE PRINTED.]
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record. It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate. The Health Care Power of Attorney should be reviewed: if the Agent or the Alternate Agent is no longer able to serve; if the Agent is your spouse and you become separated or divorced; or if you wish to revise your desires as stated in the document.
HCP_RI13
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This section explains the purpose of the document, the rights and obligations of the person making the document (the "Principal"), and the rights and obligations of the person appointed to make health care decisions for the Principal (the "Agent"). This section will appear on the printed document and should be read before the document is signed.
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An "Agent" is a person you designate to make health care decisions for you. 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.
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.)
Enter the name of the person who will act as Agent or use the P.I. Manager to select and paste a record. The Agent will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
HRI02023
Relation:#|
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;What is the Agent's relationship, if any, to the Principal?
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Statement of desires:#|
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[What are your desires concerning life-prolonging care, treatment, services, and procedures?
Your Agent must make health care decisions that are consistent with your known desires. If desired, use this space to specify any desires concerning life-prolonging care, treatment, services, or procedures. Press [Ctrl+F1] for sample provisions. You can also make your desires known to your Agent orally or by some other means.
HRI05009
Yes, include artificial feeding section.
HCP_RI05
PDo you wish to include information regarding artificial nutrition and hydration?
HRI05010
HRI05012
YesNo
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bWill your Agent be authorized to direct the discontinuation of artificial nutrition and hydration?
HRI05012
Special provisions:#|
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QWhat special provisions, if any, do you wish to state regarding your health care?
If desired, 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.
HRI05019
HRI05012
Additional statement of desires:#|
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QWhat other desires, special provisions, or limitations would you like to specify?
Use this space to include additional special provisions, desires, or limitations on your Agent's authority. 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.
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Yes. This document will expireon |.
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SDo you wish to specify the date when this power of attorney will cease to be valid?
This power of attorney will remain in effect until it is revoked unless you specify an expiration date. Enter an X to include a specific date on which the document will expire.
<Who, if anyone, will be appointed as Second Alternate Agent?
If desired, enter the Second Alternate Agent's name or use the P.I. Manager to select and paste a record. You do not have to name a second Alternate Agent.
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HRI09027
City: |
HCP_RI11
7In what Rhode Island city will this document be signed?
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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.
HCP_RI12
HRI12002
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_RI12
2What are the names and addresses of the witnesses?
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