[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_WA20
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NOTICE: The following individuals may not act as your health care Agent:
(1) Any of your physicians;
(2) An employee of any of your physicians;
(3) Owners, administrators, or employees of the health care facility where you reside or receive care;
Unless the above person is your spouse, adult child, brother, or sister.
HCP_WA01
HWA01008
Name: |City: |State: |[Include country]Country: |
HCP_WA01
HWho is this Durable Power of Attorney for Health Care being created 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.
HWA01022
Relation:#|
HCP_WA01
;What is the Agent's relationship, if any, to the Principal?
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Agent to follow Living WillAgent to decide treatmentComfort care treatment onlyAll treatment requested[Enter desires in your own words]
HCP_WA04
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.
HWA04006
HWA04011
HWA04017
If I have an incurable conditionIf I am permanently unconsciousEither of the above
HCP_WA04
aUnder what circumstances should life-sustaining treatment or procedures be withheld or withdrawn?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.
HWA04017
Specific desires:#|
HCP_WA04
EWhat are your specific desires concerning life-sustaining procedures?
HWA04017
Yes, include nutrition and fluids paragraph.
HCP_WA04
LDo you wish to state your desires regarding artificial nutrition and fluids?
HWA04019
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YesNo
HCP_WA04
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_WA04
GDo you wish to state your desires regarding life-sustaining procedures?
HWA04003
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County: |[Include SSN]SSN: |
HCP_WA17
;What are the Principal's county and social security number?
Enter the Principal's county or parish or edit the information as desired.
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HCP_WA19
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Limitations:#|
HCP_WA07
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
Yes, the Agent will have access to information regarding the Principal's health.
HCP_WA08
>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.
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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_WA09
NWill the Agent have the power to sign health care documents for the Principal?
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HCP_WA03
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Special provisions:#|
HCP_WA05
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_WA06
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.
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IGN07255
Yes.The Agent#| WILLWILL NOT#be authorized to make anatomical gifts of the Principal's body, authorize an autopsy, and direct the disposition of the Principal's remains.
HCP_WA10
kDo you wish to state whether the Agent may make decisions concerning the treatment of the Principal's body?
Enter an X if the Agent WILL be authorized to make decisions concerning anatomical gifts, an autopsy, and the disposition of remains after the Principal's death.
Enter an X if the Agent WILL NOT be authorized to make decisions concerning anatomical gifts, an autopsy, and the disposition of remains after the Principal's death.
=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_WA11
,Do you wish to designate an Alternate Agent?
IGN12003
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Agent (or Alternate)Other person
HCP_WA12
YWho do you nominate to be appointed as Guardian, if one is required by legal proceedings?
7What is the name and address of the nominated Guardian?
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Yes, include Guardian section.
HCP_WA12
#Do you wish to nominate a Guardian?
IGN13003
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HCP_WA14
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HCP_WA15
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HCP_WA16
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WITNESS STATEMENT: I declare that 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.
HCP_WA18
IHI17002
Name: |
Address 1: |
Address 2: |
City: |
State: |
Zip: |
[Include country]
Country: |
HCP_WA18
2What are the names and addresses of the witnesses?
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