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 information.
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. The Principal grants full power to the Agent, subject to limits, to make health care decisions if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This section requires that the Principal indicate whether or not the Agent may consent to organ donations. Press [Ctrl+F1] for more information.
This required section states that a Living Will executed by the Principal will be given precedence over this Declaration. Press [Ctrl+F1] for more information.
This optional section states the Principal's wishes regarding life-sustaining procedures which artificially postpone death. Press [Ctrl+F1] for more information.
This optional section states the Principal's desires regarding artificially administered nutrition and fluids. Press [Ctrl+F1] for more information.
This optional 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 Health Care Power of Attorney made by the Principal is revoked. Press [Ctrl+F1] for more information.
This required section states that if the Agent is unavailable, this document should be honored as the Principal's wishes. 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 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.
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Health Care POA
HCP_SC
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.
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! Disclosure Statement Section (1 of 14)
INFORMATION ABOUT THIS DOCUMENT
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
1. THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR AGENT THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU CANNOT MAKE THE DECISION FOR YOURSELF. THIS POWER INCLUDES THE POWER TO MAKE DECISIONS ABOUT LIFE- SUSTAINING TREATMENT. UNLESS YOU STATE OTHERWISE, YOUR AGENT WILL HAVE THE SAME AUTHORITY TO MAKE DECISIONS ABOUT YOUR HEALTH CARE AS YOU WOULD HAVE.
2. THIS POWER IS SUBJECT TO ANY LIMITATIONS OR STATEMENTS OF YOUR DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. YOU MAY STATE IN THIS DOCUMENT ANY TREATMENT YOU DO NOT DESIRE OR TREATMENT YOU WANT TO BE SURE YOU RECEIVE. YOUR AGENT WILL BE OBLIGATED TO FOLLOW YOUR INSTRUCTIONS WHEN MAKING DECISIONS ON YOUR BEHALF. YOU MAY ATTACH ADDITIONAL PAGES IF YOU NEED MORE SPACE TO COMPLETE THE STATEMENT.
3. AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE HEALTH CARE DECISIONS FOR YOURSELF IF YOU ARE MENTALLY COMPETENT TO DO SO. AFTER YOU HAVE SIGNED THIS DOCUMENT, NO TREATMENT MAY BE GIVEN TO YOU OR STOPPED OVER YOUR OBJECTION IF YOU ARE MENTALLY COMPETENT TO MAKE THAT DECISION.
4. YOU HAVE THE RIGHT TO REVOKE THIS DOCUMENT, AND TERMINATE YOUR AGENT'S AUTHORITY, BY INFORMING EITHER YOUR AGENT OR YOUR HEALTH CARE PROVIDER ORALLY OR IN WRITING.
5. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A SOCIAL WORKER, LAWYER, OR OTHER PERSON TO EXPLAIN IT TO YOU.
6. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS TWO PERSONS SIGN AS WITNESSES. EACH OF THESE PERSONS MUST EITHER WITNESS YOUR SIGNING OF THE POWER OF ATTORNEY OR WITNESS YOUR ACKNOWLEDGMENT THAT THE SIGNATURE ON THE POWER OF ATTORNEY IS YOURS.
THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:
A. YOUR SPOUSE; YOUR CHILDREN, GRANDCHILDREN, AND OTHER LINEAL DESCENDANTS; YOUR PARENTS, GRANDPARENTS, AND OTHER LINEAL ANCESTORS; YOUR SIBLINGS AND THEIR LINEAL DESCENDANTS; OR A SPOUSE OF ANY OF THESE PERSONS.
B. A PERSON WHO IS DIRECTLY FINANCIALLY RESPONSIBLE FOR YOUR MEDICAL CARE.
C. A PERSON WHO IS NAMED IN YOUR WILL, OR, IF YOU HAVE NO WILL, WHO WOULD INHERIT YOUR PROPERTY BY INTESTATE SUCCESSION.
D. A BENEFICIARY OF A LIFE INSURANCE POLICY ON YOUR LIFE.
E. THE PERSONS NAMED IN THE HEALTH CARE POWER OF ATTORNEY AS YOUR AGENT OR SUCCESSOR AGENT.
F. YOUR PHYSICIAN OR AN EMPLOYEE OF YOUR PHYSICIAN.
G. ANY PERSON WHO WOULD HAVE A CLAIM AGAINST ANY PORTION OF YOUR ESTATE (PERSONS TO WHOM YOU OWE MONEY).
IF YOU ARE A PATIENT IN A HEALTH FACILITY, NO MORE THAN ONE WITNESS MAY BE AN EMPLOYEE OF THAT FACILITY.
7. YOUR AGENT MUST BE A PERSON WHO IS 18 YEARS OLD OR OLDER AND OF SOUND MIND. IT MAY NOT BE YOUR DOCTOR OR ANY OTHER HEALTH CARE PROVIDER THAT IS NOW PROVIDING YOU WITH TREATMENT; OR AN EMPLOYEE OF YOUR DOCTOR OR PROVIDER; OR A SPOUSE OF THE DOCTOR, PROVIDER, OR EMPLOYEE; UNLESS THE PERSON IS A RELATIVE OF YOURS.
8. YOU SHOULD INFORM THE PERSON 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. IF YOU ARE IN A HEALTH CARE FACILITY OR A NURSING CARE FACILITY, A COPY OF THIS DOCUMENT SHOULD BE INCLUDED IN YOUR MEDICAL RECORD.
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").
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! Designation of Health Care Agent Section (2 of 14)
HEALTH CARE POWER OF ATTORNEY
(S.C. STATUTORY FORM)
!. DESIGNATION OF HEALTH CARE AGENT.
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 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 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. 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 Agent's 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.
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! Creation of Health Care Power of Attorney Section (3 of 14)
!. EFFECTIVE DATE AND DURABILITY. By this document I intend to create a Durable Power of Attorney effective upon, and only during, any period of mental incompetence.
This required 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.
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! Authority of Agent Section (4 of 14)
!. AGENT'S POWERS. I grant to my Agent full authority to make decisions for me regarding my health care. In exercising this authority, my Agent shall follow my desires as stated in this document or otherwise expressed by me or known to my Agent. In making any decision, my Agent shall attempt to discuss the proposed decision with me to determine my desires if I am able to communicate in any way. If my Agent cannot determine the choice I would want made, then my Agent shall make a choice for me based upon what my Agent believes to be in my best interests. My Agent's authority to interpret my desires is intended to be as broad as possible, except for any limitations I may state below.
Accordingly, unless specifically limited by Section E, below, my Agent is authorized as follows:
A. To consent, refuse, or withdraw consent to any and all types of medical care, treatment, surgical procedures, diagnostic procedures, medication, and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, nutritional support and hydration, and cardiopulmonary resuscitation;
B. To authorize, or refuse to authorize, any medication or procedure intended to relieve pain, even though such use may lead to physical damage, addiction, or hasten the moment of, but not intentionally cause, my death;
C. To authorize my admission to or discharge, even against medical advice, from any hospital, nursing care facility, or similar facility or service;
D. To take any other action necessary to making, documenting, and assuring implementation of decisions concerning my health care, including, but not limited to, granting any waiver or release from liability required by any hospital, physician, nursing care provider, or other health care provider; signing any documents relating to refusals of treatment or the leaving of a facility against medical advice, and pursuing any legal action in my name, and at the expense of my estate to force compliance with my wishes as determined by my Agent, or to seek actual or punitive damages for the failure to comply.
E. The powers granted above do not include the following powers or are subject to the following rules or limitations:
This required section states the general duties and powers of the Agent on behalf of the Principal. The Principal may state limits on the authority given to the Agent. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
Enter any rules or limitations regarding the Agent's authority.
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! Organ Donation Section (5 of 14)
!. ORGAN DONATION. [You will need to initial this provision on the printed document.]
! My Agent may
! My Agent may not
consent to the donation of all or any of my tissue or organs for purposes of transplantation.
____________________
(Initials)
This is a required section in which the Principal states his/her wishes regarding the donation of organs.
Enter an X here if the Agent WILL have the authority to consent to the donation of the organs or tissues of the Principal. Press [Ctrl+F1] for more information.
Enter an X here if the Agent WILL NOT have the authority to consent to the donation of the organs or tissues of the Principal.
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! Relationship to Living Will Section (6 of 14)
!. EFFECT ON DECLARATION OF A DESIRE FOR A NATURAL DEATH (LIVING WILL). I understand that if I have a valid Declaration of a Desire for a Natural Death, the instructions contained in the Declaration will be given effect in any situation to which they are applicable. My Agent will have authority to make decisions concerning my health care only in situations to which the Declaration does not apply.
This required section states that the provisions of any Living Will which has been executed by the Principal, and is in effect, shall take precedence over the instructions of the Agent. The Agent will only make health care decisions not addressed in a Living Will.
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! Optional Statement of Desires and Special Provisions Section (7 of 14)
!. STATEMENT OF DESIRES AND SPECIAL PROVISIONS. With respect to any Life-Sustaining Procedures, I direct the following: [You will need to initial this provision on the printed document. SELECT ONLY ONE OF THE FOLLOWING 4 PARAGRAPHS.]
! GRANT OF DISCRETION TO AGENT. I do not want my life to be prolonged nor do I want life-sustaining procedures to be provided or continued if my Agent believes the burdens of the treatment outweigh the expected benefits. I want my Agent to consider the relief of suffering, my personal beliefs, the expense involved and the quality as well as the possible extension of my life in making decisions concerning life-sustaining procedures.
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(Initials)
! DIRECTIVE TO WITHHOLD OR WITHDRAW TREATMENT. I do not want my life to be prolonged and I do not want life-sustaining procedures:
a. if I have a condition that is incurable or irreversible and, without the administration of life-sustaining procedures, expected to result in death within a relatively short period of time; or
b. if I am in a state of permanent unconsciousness.
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(Initials)
! DIRECTIVE FOR MAXIMUM TREATMENT. I want my life to be prolonged to the greatest extent possible, within the standards of accepted medical practice, without regard to my condition, the chances I have for recovery, or the cost of the procedures.
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(Initials)
! DIRECTIVE IN MY OWN WORDS:
____________________
(Initials)
Enter an X to include a section regarding the Principal's wishes regarding life-sustaining procedures. 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 gives the Agent the discretion to decide if and when life-sustaining procedures may be withdrawn or withheld. The Agent will decide if the burdens of the treatment outweigh the benefits.
Enter an X if the Principal desires that life-sustaining procedures be withdrawn or withheld if the condition of the Principal is incurable or irreversible, or if the Principal is permanently unconscious.
Enter an X if the Principal desires every possible treatment to be taken to prolong life, regardless of the cost or chances for recovery.
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining procedures. Any of the above statements may be edited or additional statements may be composed.
Use this space to indicate desires concerning life-sustaining procedures.
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! Optional Nutrition and Fluids Section (8 of 14)
!. STATEMENT OF DESIRES REGARDING TUBE FEEDING. [You will need to initial this provision on the printed document.] With respect to Nutrition and Hydration provided by means of a nasogastric tube or tube into the stomach, intestines, or veins, I wish to make clear that (INITIAL ONE OF THE FOLLOWING STATEMENTS):
I do not want to receive these forms of artificial nutrition and hydration, and they may be withheld or withdrawn under the conditions given above.
____________________
(Initials)
I do want to receive these forms of artificial nutrition and hydration.
____________________
(Initials)
[IF YOU DO NOT INITIAL EITHER OF THE ABOVE STATEMENTS, YOUR AGENT WILL NOT HAVE AUTHORITY TO DIRECT THAT NUTRITION AND HYDRATION NECESSARY FOR COMFORT CARE OR ALLEVIATION OF PAIN BE WITHDRAWN.]
Enter an X to include a section concerning the Principal's desires regarding artificially administered nutrition and fluids. Press [Ctrl+F1] for more information.
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! Optional Designation of Alternate Agent Section (9 of 14)
!. SUCCESSORS. If an Agent named by me dies, becomes legally disabled, resigns, refuses to act, becomes unavailable, or if an Agent who is my spouse is divorced or separated from me, I name the following as successors to my Agent, each to act alone and successively in the order named.
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.
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! Administrative Provisions Section (10 of 14)
!. ADMINISTRATIVE PROVISIONS.
A. I revoke any prior Health Care Power of Attorney and any provisions relating to health care of any other prior power of attorney.
B. This power of attorney is intended to be valid in any jurisdiction in which it is presented.
This required section revokes any and all previously executed Health Care Powers of Attorney, and states that this document is intended to be valid in any jurisdiction in which it is presented.
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! Unavailability of Agent Section (11 of 14)
!. UNAVAILABILITY OF AGENT. If at any relevant time the Agent or Successor Agents named herein are unable or unwilling to make decisions concerning my health care, and those decisions are to be made by a Guardian, by the Probate Court, or by a surrogate pursuant to the Adult Health Care Consent Act, it is my intention that the Guardian, Probate Court, or surrogate make those decisions in accordance with my directions as stated in this document.
This required section states that if the Agent is unavailable at any relevant time, this document shall be honored as the Principal's wishes.
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! Signature Section (12 of 14)
BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS
DOCUMENT AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT.
I sign my name to this Health Care Power of Attorney on 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. 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 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.
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! Witness Signature Section (13 of 14)
WITNESS STATEMENT
I declare, on the basis of information and belief, that the person who signed or acknowledged this document (the Principal) is personally known to me, that he/she signed or acknowledged this Health Care Power of Attorney in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence. I am not related to the Principal by blood, marriage, or adoption, either as a spouse, a lineal ancestor, descendant of the parents of the Principal, or spouse of any of them. I am not directly financially responsible for the Principal's medical care. I am not entitled to any portion of the Principal's estate upon his decease, whether under any will or as an heir by Intestate Succession, nor am I the beneficiary of an insurance policy on the Principal's life, nor do I have a claim against the Principal's estate as of this time. I am not the Principal's attending physician, nor an employee of the attending physician. No more than one witness is an employee of a health facility in which the Principal is a patient. I am not appointed as Health Care Agent or Successor Health Care Agent by this document.
This document 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.
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! Health Care Document Information Section (14 of 14)
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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