Forms
ADVANCED DIRECTIVE, MEDICAL POWER OF ATTORNEY,
HEALTH CARE AGENT
***Be sure to have an attorney advise you of the laws in your state and what is best for your own personal situation.
Medical Power of Attorney
Effective Upon Execution
ADVANCE DIRECTIVE
APPOINTMENT OF HEALTH CARE AGENT
I, ______________________________ , a resident of:
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Phone numbers and other information:
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designate _________________________________, presently residing at:
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Phone numbers and other information:
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as my Agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. My Agent shall have full power of attorney authority for health care decisions. For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical, emotional, or mental condition.
My Agent's power of attorney authority becomes operative when this document is signed. This power of attorney exists indefinitely from its date of execution, unless I revoke the power of attorney in writing.
If I am incapable of making an informed decision regarding my health care, as determined by my Agent, I direct my health care providers, after obtaining written permission from my Agent, to follow my instructions as set forth below in the Advanced Directives. I have initialed all those that apply.
If my death from a terminal condition is imminent and even if life-sustaining procedures are used there is no reasonable expectation of my recovery as determined by my Agent:
_______I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
_______I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially.
If I am in a persistent vegetative state, that is, if I am not conscious and am not aware of my environment nor able to interact with others, and there is no reasonable expectation of my recovery, as determined by my Agent:
_______I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
_______I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially.
If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, as a result of which I have suffered irreversible, severe and permanent brain damage indicated by an inability to sustain life without drastic mechanical measures and have complete physical dependency on life sustaining mechanical measures, for which, to a reasonable degree of medical certainty, all possible treatment of the irreversible condition would be medically ineffective, as determined by my Agent:
_______I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
_______I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take food and water by mouth, I wish to receive nutrition and hydration artificially.
_______I direct that, no matter what my condition, medication to relieve pain and suffering not be given to me if the medication would shorten my remaining life, as approved by my Agent.
_______I direct that, no matter what my condition, I be given all available medical treatment (including but not limited to chiropractic care, physical therapy, supplements, herbs, alternative therapies, etc.) as approved and ordered by my Agent.
I direct that all medical treatment be approved or denied by my Agent, in writing, prior to administration or removal of such treatment, including but not limited to all medications, surgeries, therapies, chiropractic care, and/or other procedures.
I direct (in the following space, indicate any other instructions regarding receipt or nonreceipt of any health care):
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Where necessary to implement the health care decisions that my Agent is authorized by this document to make, my Agent has the power and authority to execute on my behalf all of the following:
Documents titled or purporting to be a "Refusal to Permit Treatment", "DNR", and "Leaving Hospital Against Medical Advice"; Any necessary waiver or release from liability required by a hospital or physician.
Authorize my admission to or discharge from (including transfer to another facility) any hospital, hospice, nursing home, adult home, medical care facility, or private home;
Consent to the provision, withholding, or withdrawal of health care, including, in appropriate circumstances, life-sustaining procedures.
My Agent is to make health care decisions for me based on the health care instructions I give in this document and on my wishes as otherwise known to my Agent. If my wishes are unknown or unclear, my Agent (and my Agent ONLY) is to make health care decisions for me in accordance with my best interest, to be determined by my Agent after considering the benefits, burdens, and risks that might result from a given treatment or course of treatment, or from the withholding or withdrawal of a treatment or course of treatment. A second opinion from a trusted medical professional who is chosen solely by my Agent shall be obtained if they so desire.
My Agent has permission to consent to the disclosure of this information. No information will be disclosed to other parties without the Agents written permission, which will be determined on a case by case basis. This includes any and all medical records, for any purpose.
My Agent shall have full access to all current and past medical records, pharmacy/medication notes and prescriptions, physicians and other medical professionals notes and reports, legal records and notes, nurses and nurses aids notes or reports, x-rays, MRI’s, SPECT scans, ultrasounds, cardiac tests, physical therapy notes, lab reports, etc. and shall immediately upon their request, be provided copies of any and all records generated throughout my lifetime.
My Agent shall not be liable for the costs of care based on this authorization or otherwise.
My Agent has permission to authorize release of and obtain donations of tissues, organs, fluids, and other material for testing and/or research purposes, to be sent to facilities of their choice at the time of my death.
In the event that my designated Agent, ____________________________, becomes unable or unwilling to serve I hereby designate _____________________________ presently residing at:
____________________________________________
____________________________________________
Phone numbers and other information:
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as my as my alternate agent.
I revoke any prior Medical Power of Attorney on file at any medical institution or medical professionals office.
By signing below, I indicate that I am emotionally and mentally competent to make this appointment of a health care agent, assign a power of attorney, and complete an Advanced Directive, and that I understand the purposes and effects.
The original copy of this Medical Power of Attorney is located at:
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Signed copies of this Medical Power of Attorney have been filed with the following individuals and institutions:
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Attending family physician or specialists
OTHER-
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I sign my name to this Medical Power of Attorney and Advanced Directives on the date of ____________________________________, at the following location:
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____________________________________________
_______________________________
NAME- Signature
_______________________________
NAME- Print
Statement of witnesses:
I hereby declare under penalty of perjury that the person who signed or acknowledged this document is personally known to me (or proved to me on the basis of convincing evidence) to be the principal, that the principal signed or acknowledged this durable medical power of attorney 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 an agent by this document. I am not related to the principal by blood, marriage, or adoption. I would not be entitled to any portion of the principal's estate on the principal's death. I am not the attending physician of the principal or an employee of the attending physician. I have no claim against any portion of the principal's estate on the principal's death. Furthermore, if I am an employee of a health care facility in which the principal is a patient, I am not involved in providing direct patient care to the principal and am not an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility.
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Witness Signature and date
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Address and phone number
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2nd Witness Signature and date
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2nd Address and phone number
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Subscribed and sworn to before me on [DATE].
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Notary Public, [COUNTY, STATE]
My commission expires ______________________________________