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 states that a power of attorney for health care is being created. It shall only be effective when the Principal is unable to make decisions regarding health care. Press [Ctrl+F1] for information.
This required section describes the authority given to the Agent. The Principal grants full power to the Agent to make health care decisions if 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, and artificial nutrition. Press [Ctrl+F1] for more information.
This optional 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.
The Principal may select this optional section to specify any values or preferences, such as religious beliefs, location of care or personal values, which pertain to this document. Press [Ctrl+F1] for more information.
This optional section enables the Principal to establish specific limitations upon the decision making authority of the Agent. Press [Ctrl+F1] for more information.
This optional 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.
In many cases, documents concerning treatment of the Principal must be signed. If the Principal is unable to do so, this optional section gives the Agent that authority. Press [Ctrl+F1] for more information.
This optional section 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 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 any person or entity who faithfully carry 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 the Principal's intentions for this document to be legally binding. 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].
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 section requires 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_SD
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.
This is a state-specific document. Enter the Principal's state/province or edit the information as desired. The state in this field should be the same as the state shown at the top of the screen.
Enter an X to include the Principal's country, if outside the United States.
Enter the country or edit the information as desired.
IGN01
! Designation of Health Care Agent Section (1 of 18)
HEALTH CARE POWER OF ATTORNEY
!. DESIGNATION OF HEALTH CARE AGENT.
I, !,
of !, !,
! Country: !,
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 and personal decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.
NOTICE: Generally you should not appoint any of the following persons as your Agent:
(1) your treating physician or health care provider;
(2) an employee of your physician or health care provider unless the person is your relative;
(3) your residential care provider; or
(4) an employee of your residential care provider unless the person is your relative.
This is the beginning of the 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 he/she 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.
This is a state-specific document. Enter the Principal's state/province or edit the information as desired. The state in this field should be the same as the state shown at the top of the screen.
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 you if you are 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 at which the Agent may be reached during non-business hours.
Enter a phone number at which the Agent may be reached during business hours, if different from the home phone number.
Enter the relationship of the Agent to the Principal.
IGN02
! Creation of Health Care Power of Attorney Section (2 of 18)
!. CREATION OF HEALTH CARE POWER OF ATTORNEY. By this document I intend to create a Health Care Power of Attorney. This power of attorney shall take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency.
This is a required section which states that a Health Care 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.
HSD03
! Authority of Agent Section (3 of 18)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I 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. My Agent shall not make a health care decision for me if my attending physician has determined in good faith that I have decisional capacity.
Whenever making any health care decision, my Agent shall consult the recommendation of my attending physician, consider the decision I would have made if I had the decisional capability, if known, and the decision that my Agent believes to be in my best interests. All such decisions shall be made in accordance with accepted medical practice.
This required section 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.
HSD04
! Optional Life-Sustaining Treatment Section (4 of 18)
!. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING CARE, TREATMENT, SERVICES AND PROCEDURES: [Choose one of 5 choices; last choice allows you to compose your own statement.]
! I specifically direct my Agent to follow any "living will" executed by me.
! I do not want my life to be prolonged nor do I want life-sustaining treatment 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 treatment.
! I do not want my life to be prolonged and I do not want life-sustaining treatment, except to the extent deemed necessary to provide me with comfort care,
! if I have a condition that is incurable or irreversible and, without the administration of life-sustaining treatment, expected to result in death within a relatively short time.
! if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! if I have a condition that is incurable or irreversible and, without the administration of life-sustaining treatment, expected to result in death within a relatively short time, or if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! 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.
! [User to compose own statement of desires concerning life-sustaining treatment]
Enter an X to include a section concerning the Principal's wishes regarding life-sustaining treatment. 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 Agent is to follow any "living will" executed by the Principal. A living will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his or her intention that life-sustaining treatment be withdrawn or withheld under certain conditions.
Enter an X if the Principal gives the Agent the discretion to decide if and when life-sustaining treatment 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 life-sustaining treatment to be given only to the extent of providing the Principal with comfort care.
Enter an X to withhold life-sustaining treatment if the condition of the Principal is incurable or irreversible.
Enter an X to withhold life-sustaining treatment if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-sustaining treatment if the Principal's condition is incurable or if the Principal is in a permanently unconscious state.
Enter an X if the Principal desires every possible procedure to be taken to prolong life to the greatest extent, regardless of cost or chances for recovery.
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining treatment. Any of the above statements may be edited or additional statements may be composed.
Use this space to indicate desires concerning life-sustaining treatment.
HSD05
! Continuation of Life-Sustaining Treatment Section (4 of 18)
!. STATEMENT OF DESIRES CONCERNING NUTRITION AND FLUIDS. Artificial nutrition or hydration may be withheld or withdrawn if:
(a) Artificial nutrition or hydration is not needed for comfort care or the relief of pain and the attending physician reasonably believes that the Principal's death will occur within approximately one week; or
(b) Artificial nutrition or hydration cannot be physically assimilated by the Principal; or
(c) The burden of providing artificial nutrition or hydration outweighs its benefit, provided that the determination of burden refers to the provision of artificial nutrition or hydration itself and not to the quality of the continued life of the Principal.
Even in the exceptions listed in subdivisions (a), (b) and (c), artificial nutrition and hydration may not be withheld or withdrawn if it is needed for comfort or the relief of pain.
Artificially provided nutrition or fluids provided by means of a nasogastric tube or tube into the stomach, intestines, or veins,
! shall be
! shall NOT be
among the "life-sustaining treatment" that may be withheld or withdrawn under the conditions given above.
Enter an X to include a section which states the Principal's wishes regarding artificially administered nutrition and fluids. Press [Ctrl+F1] for more information.
Enter an X if artificial nutrition and fluids SHALL be among the life-sustaining treatment that may be withheld or withdrawn by the Agent's authorization.
Enter an X if artificial nutrition and fluids SHALL NOT be among the life-sustaining treatment that may be withheld or withdrawn by the Agent's authorization.
IGN06
! Optional Special Provisions Section (5 of 18)
!. SPECIAL PROVISIONS REGARDING MY HEALTH CARE. (For example, describe your wishes regarding any treatment you desire or do not desire, or admission to a residential care facility.)
Enter an X to include a section regarding special provisions concerning health care which are not otherwise contained in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
Use this space to describe any additional special provisions.
IGN07
! Optional Values And Preferences Section (6 of 18)
!. STATEMENT OF VALUES AND PREFERENCES. (Specify any other wishes, values, religious beliefs, philosophy or other personal values or preferences that are relevant to your instructions. You may also state preferences concerning the location of your care.)
Enter an X to include a section concerning values and preferences about health care. For example, describe values or religious preferences, or the location of treatment. Press [Ctrl+F1] for more information.
Use this space to specify values and preferences.
IAL07
! Optional Limits on Agent's Authority Section (7 of 18)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT:
Enter an X to include a section that allows the Principal to establish limitations 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.
Use this space to specify any limits on the Agent's authority to make decisions on behalf of the Principal.
IAL08
! Optional Inspection and Disclosure Section (8 of 18)
!. 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:
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. Consent to the disclosure of this information to others.
Enter an X to include a provision which 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.
IAL09
! Optional Signing Documents, Waivers, and Releases Section (9 of 18)
!. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. 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:
a. Documents to authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care or assisted living or similar facility or service;
b. Documents titled or purporting to be "Consent to Permit Treatment" or "Refusal to Permit Treatment"; or
c. Any necessary waiver or release from liability required by a hospital or physician.
Enter an X to include a section which 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.
IGN12
! Optional Designation of Alternate Agent Section (10 of 18)
!. DESIGNATION OF ALTERNATE AGENT. If the person designated as my Agent is not available or unable to act, I designate the following persons to serve as my Agent to make health care decisions for me as authorized by this document, who serve in the following order:
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 the 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 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.
IGN15
! Revocation Section (11 of 18)
!. PRIOR DESIGNATIONS REVOKED. I revoke any prior Health Care Power of Attorney.
This required revocation section states that any prior Health Care Power of Attorney made by the Principal is revoked. Press [Ctrl+F1] for more information.
IGN16
! Hold Harmless Section (12 of 18)
!. 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 (13 of 18)
!. 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 (14 of 18)
!. 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.
HSD16
! Signature Section (15 of 18)
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I have read and understand the contents of this document and the effect of this grant of powers to my Agent. I am emotionally and mentally competent to make this declaration.
This section requires the signature of the Principal in the presence of two witnesses and 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 an earlier 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.
HSD17
! Witness Signature Section (16 of 18)
READ AND CAREFULLY FOLLOW THE WITNESSING PROCEDURE.
IT REQUIRES TWO WITNESSES AND A NOTARY TO FORMALIZE THIS
DOCUMENT ALTHOUGH YOUR STATE HAS NOT ENACTED
A HEALTH CARE POWER OF ATTORNEY STATUTE.
STATEMENT OF WITNESSES
I declare that the person who signed or acknowledged this document (the "Principal") has identified himself or herself to me, that the Principal signed or acknowledged this document in my presence, that the Principal appears to be of sound mind, and under no duress, fraud or undue influence. I am not the person appointed as Agent or Alternate Agent by this document, nor am I a provider of health or residential care, an employee of a provider of health or residential care, the operator of a community care facility, or an employee of an operator of a health care facility.
I further declare that I am not related to the Principal by blood, marriage, or adoption, and to the best of my knowledge, I am not a creditor of the Principal or entitled to any part of the estate of the Principal under a will now existing or by operation of law.
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.
HSD18
! Notary Section (17 of 18)
State of _________________________,
County of _________________________ ss:
On this _____ day of _______________, 19___, !, known to me (or satisfactorily proven) to be the person named in the foregoing instrument, personally appeared before me, a Notary Public, within and for the said State and County, and acknowledged that he/she freely and voluntarily executed the same for the purposes stated in the document.
My commission expires: _____________________
_____________________________________
Notary Public
This section requires the signature of a Notary Public to acknowledge that the Principal signed this document. The Principal's name was transferred from a previous section and can be modified only by returning to that section. Press [Ctrl+F1] for more information.
DOM01
! Health Care Document Information Section (18 of 18)
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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