[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_SD19
{NEXT_?}
HCP_SD03
{NEXT_?}
Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
HCP_SD04
<What are your desires concerning life-sustaining treatments?
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining treatment.
HSD04006
HSD04011
{NEXT_?}
If I have an incurable conditionIf I am permanently unconsciousEither of the above
HCP_SD04
SUnder what circumstances should life-sustaining treatment be withheld or withdrawn?
{NEXT_?}
Specific desires:#|
HCP_SD04
DWhat are your specific desires concerning life-sustaining treatment?
Use this space to indicate desires concerning life-sustaining treatment. The previous statements may be edited or additional statements may be composed.
{NEXT_?}
Yes, include life-sustaining treatment section.
HCP_SD04
FDo you wish to state your desires regarding life-sustaining treatment?
HSD04003
{NEXT_?}
YesNo
HCP_SD05
Will artificially provided nutrition and fluids be included in the "life-sustaining treatment" that may be withheld or withdrawn?
{NEXT_?}
Yes, include nutrition/fluids section.
HCP_SD05
[Do you wish to state your desires regarding artificially administered nutrition and fluids?
HSD05003
{NEXT_?}
County: |[Include SSN]SSN: |
HCP_SD16
;What are the Principal's county and social security number?
Enter the Principal's county or edit the information as desired.
{NEXT_?}
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_SD17
2What are the names and addresses of the witnesses?
{NEXT_?}
HSD17002
HCP_SD18
{NEXT_?}
Limitations:#|
HCP_SD08
nWhat limitations, if any, will there be on the Agent's authority to make decisions on behalf of the Principal?
If desired, specify any limitations on the Agent's authority. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
{NEXT_?}
IAL07255
Yes, the Agent will have access to information regarding the Principal's health.
HCP_SD09
>Will the Agent have access to the Principal's medical records?
Enter an X if the Agent will have the authority (subject to any stated limitations) to: (a) request, review and receive any information regarding the Principal's physical or mental health, including, but not limited to, medical and hospital records; and (b) consent to the disclosure of this information to others.
{NEXT_?}
Yes. The Agent may execute: (a) documents to authorize my admission to or discharge from any health care facility; (b) documents consenting to or refusing treatment; and (c) any waiver or liability release required by a hospital or physician.
HCP_SD10
NWill the Agent have the power to sign health care documents for the Principal?
{NEXT_?}
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.
HCP_SD01
IGN01010
Name: |City: |State: |[Include country]Country: |
HCP_SD01
<Who is this Health Care Power of Attorney being created for?
This is a state-specific document. Enter the Principal's state or edit the information as desired.
Enter the Agent's name 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.
IGN01022
Relation:#|
HCP_SD01
;What is the Agent's relationship, if any, to the Principal?
{NEXT_?}
HCP_SD02
{NEXT_?}
Special provisions:#|
HCP_SD06
IWhat special provisions, if any, do you wish to include in this document?
If desired, enter any special health care provisions that you would like to include in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
{NEXT_?}
IGN06255
Values and preferences:#|
HCP_SD07
DWhat personal values, if any, do you wish to state in this document?
If desired, specify any values and preferences about health care. For example, describe values or religious preferences, or your desires regarding the location of treatment. Press [Ctrl+F1] for more information.
=Who, if anyone, will be designated 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.
(.txt)