[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_VT16
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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, as well as the rights and obligations of the person making the document (the "Principal") and the person appointed to make health care decisions for the Principal (the "Agent").
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.
HCP_VT01
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NOTICE: The following persons may not serve as Agent:
A. the Principal's health care provider;
B. a nonrelative of the Principal who is an employee of the Principal's health care provider;
C. the Principal's residential care provider; or
D. a nonrelative of the Principal who is an employee of the Principal's residential care provider.
HCP_VT02
HVT02006
Name: |
HCP_VT02
HWho is this Durable Power of Attorney for Health Care being created 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.
HVT02018
Relation:#|
HCP_VT02
;What is the Agent's relationship, if any, to the Principal?
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Comfort care treatment onlyComfort care treatment and artificial nutrition/hydration onlyAll treatment requested[Enter desires in your own words]
HCP_VT03
;What are your desires concerning life-sustaining treatment?
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining treatment.
HVT03007
HVT03013
Specific desires:#|
HCP_VT03
DWhat are your specific desires concerning life-sustaining treatment?
HVT03013
Yes, include nutrition and fluids statement.
HCP_VT03
LDo you wish to state your desires regarding artificial nutrition and fluids?
HVT03015
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YesNo
HCP_VT03
Will artificially administered nutrition and fluids be included in the "life-sustaining treatment" that may be withheld or withdrawn?
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Yes, include life-sustaining procedures section.
HCP_VT03
GDo you wish to state your desires regarding life-sustaining procedures?
Enter the Principal's city or edit the information as desired.
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WITNESSES: The Durable Power of Attorney for Health Care shall be signed by the Principal in the presence of at least two or more subscribing witnesses, neither of whom shall, at the time of execution, be the Agent, the Principal's health or residential care provider or the provider's employee, the Principal's spouse, heir, a person entitled to any part of the estate of the Principal upon the death of the Principal under a will or deed in existence or by operation of law or any other person who has, at the time of execution, any claims against the estate of the Principal.
HCP_VT14
HVT14002
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_VT14
2What are the names and addresses of the witnesses?
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HVT14002
Yes, include the statement.
HCP_VT15
NDo you wish to include a statement by an Ombudsman or hospital Representative?
Enter an X to include a section in which an Ombudsman or hospital Representative states that he or she has personally explained the nature and effect of this document to the Principal. This section should only be included if the Principal is in, or is being admitted to, a hospital, nursing home, or residential care home.
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Limitations:#|
HCP_VT06
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
Special provisions:#|
HCP_VT04
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_VT05
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.
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IGN12027
Yes, include Alternate Agent section.
HCP_VT09
,Do you wish to designate an Alternate Agent?
IGN12003
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Agent (or Alternate)Other person
HCP_VT10
YWho do you nominate to be appointed as Guardian, if one is required by legal proceedings?
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