[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.
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This section contains a Disclosure Statement which explains the purpose and consequences of this Durable Power of Attorney for Health Care. The Disclosure Statement will appear on the printed document and must be read and understood by the Principal before he or she signs the Durable Power of Attorney for Health Care. Press [Ctrl+F1] for more information.
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Name: |
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=Who is this Health Care Power of Attorney being prepared for?
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.
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Relation:#|
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;What is the Agent's relationship, if any, to the Principal?
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By this document I intend to create a Durable Power of Attorney effective upon, and only during, any period of mental incompetence.
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AGENT IS AUTHORIZED: 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, nutrition 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;
[Agent's authority continued in next question.]
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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 and assuring implementation of decisions concerning my health care, including, but not limited to, granting any release from liability required by any hospital, physician, or other health care provider; signing any documents relating to refusals of treatment, 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.
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Agent's powers or limitations:#|
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:What are the Agent's additional powers and/or limitations?
Enter any other information regarding the Agent's authority, including any rules or limitations on the previously listed powers.
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YesNo
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OWill the Agent have the authority to make a donation of your organs or tissues?
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Agent to decide treatmentWithhold or withdraw treatmentAll treatment requested[Enter desires in your own words]
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MWhat are your desires concerning life-sustaining treatment and/or procedures?
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining procedures.
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Specific desires:#|
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VWhat are your specific desires concerning life-sustaining treatment and/or procedures?
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Yes, include life-sustaining procedures section.
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GDo you wish to state your desires regarding life-sustaining procedures?
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Yes, include nutrition/hydration section.
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PDo you wish to include information regarding artificial nutrition and hydration?
Enter an X to include a section concerning the Principal's desires regarding artificially administered nutrition and fluids. Several optional provisions will appear in this section in the printed document. The Principal must initial one of the provisions. Press [Ctrl+F1] for more information.
<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.
WITNESS STATEMENT: The Principal is personally known to me. He/she signed or acknowledged this document in my presence, and he/she appears to be of sound mind and under no duress or undue influence. I am not related to the Principal by blood, marriage, or adoption. I am not directly financially responsible for the Principal's medical care. I am not entitled to any portion of the Principal's estate, nor am I the beneficiary of any life insurance policy on the Principal. I do not have a claim against the Principal's estate. I am not the Principal's attending physician, nor the attending physician's employee. 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.
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Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
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2What are the names and addresses of the witnesses?
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