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. Press [Ctrl+F1] for more information.
This required section states the authority the Agent is given. The Principal grants full power to the Agent to make health care decisions if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This required section describes when the Agent's authority will begin and how long this authorization will remain effective. Press [Ctrl+F1] for more information.
This section requires the Principal to sign the document in the presence of a Notary Public. 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_UT
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becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures should be withheld or withdrawn under certain circumstances, and designates a person who will have authority to make health care decisions for the Principal, if the Principal is unable to do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.
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.
HUT01
! Designation of Health Care Agent Section (1 of 5)
[A person 18 years of age or older may designate any other person 18 years of age or older to make all medical treatment decisions (not just in case of terminal illness) if the patient is unable to make such decisions.]
SPECIAL POWER OF ATTORNEY
I, !, of !, !,
! Country: !,
this _____ day of _______________, 19___, being of sound mind, willfully and voluntarily appoint:
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
as my Agent and Attorney-in-Fact, without substitution, with lawful authority to execute a directive on my behalf under Section 75-2-1105, governing the care and treatment to be administered to or withheld from me at any time after I incur an injury, disease, or illness which renders me unable to give current directions to attending physicians and other providers of medical services.
This required section states the name and address of the person appointed as your Attorney-in-Fact ("Agent") to execute a directive for care and treatment, or withholding treatment, if you (as the Principal) are unable to make health care 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.
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 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 directives 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 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.
HUT02
! Authority of Agent Section (2 of 5)
I have carefully selected the above-named Agent with confidence in the belief that this person's familiarity with my desires, beliefs, and attitudes will result in directions to attending physicians and providers of medical services which would probably be the same as I would give if able to do so.
This required section describes the types of power the health care Agent will have. You should discuss your preferences with your Agent so he/she can make health care decisions/directives for you. Press [Ctrl+F1] for more information.
HUT03
! Duration Section (3 of 5)
This power of attorney shall be and remain in effect from the time my attending physician certifies that I have incurred a physical or mental condition rendering me unable to give current directions to attending physicians and other providers of medical services as to my care and treatment.
This required section describes when the Agent's authority will begin, and how long this authorization will remain effective. Press [Ctrl+F1] for more information.
HUT04
! Signature Section (4 of 5)
(THIS SPECIAL POWER OF ATTORNEY MUST BE SIGNED BEFORE A NOTARY PUBLIC)
On the _____ day of _______________, 19___, personally appeared before me !, who duly acknowledged to me that he/she has read and fully understands the foregoing power of attorney, executed the same of his own volition and for the purposes set forth, and that he was acting under no constraint or undue influence whatsoever.
________________________________________
Notary Public
My commission expires: _________________________
Residing at: ___________________________________
This section requires the Principal to sign the document in the presence of a Notary Public. 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.
Enter the county/parish or edit the information as desired. The other address information was transferred from a previous 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.
DOM01
! Health Care Document Information Section (5 of 5)
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.
(.txt)