[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_TX13
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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.
HCP_TX01
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The following persons may NOT be appointed as Agent for the Principal:
1) The Principal's health care provider.
2) A nonrelative of the Principal who is an employee of the Principal's health care provider.
3) The Principal's residential care provider.
4) A nonrelative of the Principal who is an employee of the Principal's residential care provider.
HCP_TX02
HTX02006
Name: |
HCP_TX02
=Who is this Health Care Power of Attorney being prepared for?
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.
HTX02018
Relation:#|
HCP_TX02
;What is the Agent's relationship, if any, to the Principal?
<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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HTX07027
Yes, include Alternate Agent section.
HCP_TX07
,Do you wish to designate an Alternate Agent?
HTX07003
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Yes. This document will expireon |.
HCP_TX08
IDo you wish to specify a certain date on which this document will expire?
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HCP_TX10
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City: |State: |
HCP_TX11
#Where will this document be signed?
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WITNESS STATEMENT: I am not the person appointed as Agent by this document, and I am not 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 am not related to the Principal by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the Principal upon the death of the Principal under a will or by operation of law.
HCP_TX12
HTX12002
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_TX12
2What are the names and addresses of the witnesses?
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HTX12002
Limitations:#|
HCP_TX06
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.
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IAL07255
Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
HCP_TX03
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.
IGN04006
IGN04011
IGN04022
If I have an incurable conditionIf I am permanently unconsciousEither of the above
HCP_TX03
aUnder what circumstances should life-sustaining treatment or procedures be withheld or withdrawn?
Enter an X to withhold life-sustaining procedures if the condition of the Principal is incurable or irreversible and is expected to result in death within a relatively short time without such procedures.
Enter an X to withhold life-sustaining procedures if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-sustaining procedures if the Principal's condition is incurable and is expected to result in death within a relatively short time (without such procedures) or if the Principal is in a permanently unconscious state.
IGN04022
Specific desires:#|
HCP_TX03
VWhat are your specific desires concerning life-sustaining treatment and/or procedures?
IGN04022
Yes, include nutrition and fluids paragraph.
HCP_TX03
LDo you wish to state your desires regarding artificial nutrition and fluids?
IGN04023
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YesNo
HCP_TX03
Will artificially administered nutrition and fluids be included in the "life-sustaining procedures" that may be withheld or withdrawn?
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Yes, include life-sustaining procedures section.
HCP_TX03
GDo you wish to state your desires regarding life-sustaining procedures?
IGN04003
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Special provisions:#|
HCP_TX04
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.
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IGN06255
Values and preferences:#|
HCP_TX05
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.
(.txt)