Power Of Attorney For Health Care For «HusbandName» [Similar Form For Wife Included In Package]

                                  

1. NOTICE TO PERSON MAKING THIS DOCUMENT: You have the right to make decisions about your health care. No health care may be given to you over your obj [Portion Redacted - Included In Fully Licensed Version] nd necessary health care may not be stopped or withheld if you object.

 

Because your health care providers in some cases have not had the opportunity to establis [Portion Redacted - Included In Fully Licensed Version] r beliefs and values and the details of your family relationships. This poses a problem if you beco [Portion Redacted - Included In Fully Licensed Version] me physically or mentally unable to make decisions about your health care.

 

In order to avoid this problem you may sign this legal document to specify the person whom you want to make health care decisions for you if you are unable to ma [Portion Redacted - Included In Fully Licensed Version] e decisions personally. That person is known as your health care agent. You should take some time to discuss your thoughts and beliefs about medical treatment with the person or persons whom you have specified. You may state in this document a [Portion Redacted - Included In Fully Licensed Version] s of health care that you do or do not desire, and you may limit the authority of your health care agent as you wish. If your health care agent is unaware of your desires with respect to a particular health care decision, he or [Portion Redacted - Included In Fully Licensed Version] required to determine what would be in your best interests in making the decision.

 

This is an important legal document. It gives the person whom you specify broad powers to make [Portion Redacted - Included In Fully Licensed Version] e decisions for you. It revokes any prior power of attorney for health care t [Portion Redacted - Included In Fully Licensed Version] ou have made. If you change your mind about whether a person should make health care decisions for you, or about which person that should be, you may revoke thi [Portion Redacted - Included In Fully Licensed Version] at any time by destroying the document or directing another person to destroy it in your presence, revoking it in written statement which you sign and d [Portion Redacted - Included In Fully Licensed Version] ing that it is revoked in the presence of two witnesses. If you revoke, you should notify the person you had specified, your health [Portion Redacted - Included In Fully Licensed Version] and any other person to whom you have given a copy. If the person you have specified is your spouse and your marriage is annulled or you are divorced after signing this document, [Portion Redacted - Included In Fully Licensed Version] ment is invalid. 

 

Do not sign this document unless you clearly understand what it means.  It is suggested that you keep the original of this document on file with your physician.

 

Instrument made on this ____ day of _____________, 200___.

 

2. CREATION OF POWER OF ATTORNEY FOR HEALTH CARE:  TO MY FAMILY, DOCTORS AND ALL THOSE CONCERNED WITH MY CARE: I, «HusbandName», being of sound [Portion Redacted - Included In Fully Licensed Version] d by this document to create a power of attorney for health care. My ex [Portion Redacted - Included In Fully Licensed Version] is power to create a power of attorney for health care is voluntary. I expect, despite the creation of this power of attorney for health care, to be fully informed about and allowed to participate in any health care d [Portion Redacted - Included In Fully Licensed Version] n for me, to the extent that I am able. For the purposes of this document, "health care decision" means an informed decision in the exercise of my right to accept, maintain, discontinue or refuse any care, treatment service or procedure to maintain, diagnose or treat [Portion Redacted - Included In Fully Licensed Version] l or mental condition.

 

3. DESIGNATION OF HEALTH CARE AGENT: If I am no longer able to make health care decisions for myself, due to my incapacity, I hereby designate «WifeName» to be my health care agent for the purpose of making health car [Portion Redacted - Included In Fully Licensed Version] decisions on my behalf. If she is ever unable or unwilling to do so, I hereby designate  «HusbandHCPA_1», «HusbandHCPA_1_Add»,  «HusbandHCPA_1_CSZ»: «HusbandHCPA_1_Phone», to be my alter [Portion Redacted - Included In Fully Licensed Version] sions on my behalf. If «HusbandHCPA_1» is unable or unwilling to act as my health care agent, I hereby designate «HusbandHCPA_2», «HusbandHCAP_2_Add», «HusbandHCPA_2_CSZ»: «HusbandHCPA_2_Phone». Neither the health care agent or the alter [Portion Redacted - Included In Fully Licensed Version] ts whom I have designated are my health care provider, an employee of my health care provider or an employee of a health care facility in which I reside or am a patient or a spouse of  any of those persons, or, if he or she is that health care provider or employee or spouse of that health care provider or employe [Portion Redacted - Included In Fully Licensed Version] e or she is also my relative. For purposes of this document, "incapacity" exists if 2 physicians or a physician and psychologist who have personally examined [Portion Redacted - Included In Fully Licensed Version] a statement that specifically expresses their opinion that I have a condition that means that I am unable to receive and evaluate information effectively or to communicate decisions to such an extent that I lack the capacity to manage my health ca [Portion Redacted - Included In Fully Licensed Version] copy of that statement, if made, must be attached to this document.

 

4. GENERAL STATEMENT OF AUTHORITY GRANTED: Unless I have specified otherwise in this document, if I ever have incapacity I instruct my health care provider to [Portion Redacted - Included In Fully Licensed Version] the health care decision of my health care agent for all of my health care. I have discussed my desires thoroughly with my health care agent and believe t [Portion Redacted - Included In Fully Licensed Version] e or she understands my philosophy regarding the health care decisions I would make if I were so able. I desire that my wishes be carried out through the authority given to my health care agent und [Portion Redacted - Included In Fully Licensed Version] ocument.

 

My health care agent is instructed that if I am unable, due to my incapac [Portion Redacted - Included In Fully Licensed Version] ke a health care decision he or she shall make a health care decision for me, except that in exercising the authority given to h [Portion Redacted - Included In Fully Licensed Version] her by this document my health care agent should try to discuss with me any specific proposed health care if [Portion Redacted - Included In Fully Licensed Version] e to communicate in any manner, including by blinking my eyes. If this communication cannot be made, my health care agent shall base his or her health care decisions on any health care choices that I have expressed prior to the time of the decision. If I hav [Portion Redacted - Included In Fully Licensed Version] pressed a health care choice about the health care in question and communication cannot be made, my health care agent shall base his or her health care decision on what he or she believes to be in my best interest.

 

5. LIMITATIONS ON MENTAL HEALTH TREATMENT: My heal [Portion Redacted - Included In Fully Licensed Version] gent may not admit or commit me on an inpatient basis to an institution for mental diseases, an intermediate care facility for the mentally retarded, a sta [Portion Redacted - Included In Fully Licensed Version] facility or a treatment facility. My health care agent may not consent to experimental mental health research or psychosurgery, electroconvulsive treatment or other drastic mental health treat [Portion Redacted - Included In Fully Licensed Version] edures for me.

 

6. ADMISSION TO NURSING HOMES OR COMMUNITY-BASED RESIDENTIAL FACILITIES: My health care agent may admit me to a nursing home or community-based residential facility for short-term stays for recuperative care or respite care.

If I am diagnosed as mentally ill or developmentally disabled, my health care agent may not admit me to a nursing home or community-based residential facility for a purpose other than recuperative care or respite care.

If I am not diagnosed as mentally ill or developmentally disabled, and if I have checked "Yes" to the following, my health care agent may admit me for a purpose other than recuperative care or respite care to:

 

(1) A nursing home            ___X__Yes ______No

(2) A community-based

     residential facility     ___X__Yes ______No

 

If I have [Portion Redacted - Included In Fully Licensed Version] checked either "Yes" or "No" to admission to a nursing home or community-based residential facility for a purpose other then recuperative care or respite care, my health care agent may o [Portion Redacted - Included In Fully Licensed Version] t me for short-term stays for recuperative care or respite care.

 

7. PROVISION OF NUTRITION AND HYDRATION: If I have checked "Yes" to the following, my health care agent may have nonorally ingested nutrition and hydration wit [Portion Redacted - Included In Fully Licensed Version] rawn from me, unless my physician has advised that, in his or her professional judgement, this will cause me pain or will reduce my comfort. If I [Portion Redacted - Included In Fully Licensed Version] ed "No" to the following, my health care agent may not have nonorally ingested [Portion Redacted - Included In Fully Licensed Version] and hydration withheld or withdrawn  from me.

My health care agent may [Portion Redacted - Included In Fully Licensed Version] ve orally ingested nutrition or hydration withheld or withdrawn from [Portion Redacted - Included In Fully Licensed Version] s provision of the nutrition or hydration is medically contraindicated.

 

Withhold or withdraw non-orally ingested nutrition and hydration

 

______Yes ______No

 

If I have [Portion Redacted - Included In Fully Licensed Version] checked either "Yes" or "No" to withholding or withdrawing nonorally ingested nutrition and hydration, my health care agent [Portion Redacted - Included In Fully Licensed Version] not have nonorally ingested nutrition and hydration withdrawn from me.

 

     8. HEALTH CARE DECISIONS FOR PREGNANT WOMEN: If [Portion Redacted - Included In Fully Licensed Version] ve checked "Yes" to the following, my health care agent may make health care decisions for me even if my agent knows I am pregnant. If I have check [Portion Redacted - Included In Fully Licensed Version] o the following , my health care agent may not make health care decisions for me if my health care agent knows I am pregnant.

 

Health care decisio [Portion Redacted - Included In Fully Licensed Version] am pregnant   _____Yes  _____No

 

If I have not checked either "Yes" or "No" to permitting my health care agent to make h [Portion Redacted - Included In Fully Licensed Version] are decisions for me if I am known to be pregnant, my health care agent may not make health car [Portion Redacted - Included In Fully Licensed Version] sions for me if my health care agent knows I am pregnant.

 

9. STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS: In exercising authority under this document, my health care agent shall act consisten [Portion Redacted - Included In Fully Licensed Version] my following stated desires, if any, and is subject to any special provisions or limitations that I specify. The following are any [Portion Redacted - Included In Fully Licensed Version] desires, provisions or limitations that I wish to state (add more items if needed):

 

(1)  

(2)

(3)

 

                    10.  INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH: Subject [Portion Redacted - Included In Fully Licensed Version] imitations in this documentation, my health care agent has the authority to do all of the following:

    

(1)  Request, review and receive any information, verbal or written, regarding my physical or mental health, including medical and hospital records.

(2)  Execute on my behalf any documents that may be required in order to obtain this information.

(3)  Consent to the disclosure [Portion Redacted - Included In Fully Licensed Version] his information.

 

11.  SIGNING DOCUMENTS, WAIVERS RELEASES: Where necessary to

implement the health care decisions that [Portion Redacted - Included In Fully Licensed Version] h care agent is authorized by this document to make, my health care agent has the authority to execute on my behalf any of the following:

 

(1)  Documents titled or purporting to be a "Consent Permit Treatment," "Refusal to Pe [Portion Redacted - Included In Fully Licensed Version] ment," or "Leaving Hospital Against M [Portion Redacted - Included In Fully Licensed Version] Advice."

(2)  A waiver or release from liability required by a hospital or physician.

 

12. SIGNATURE OF PRINCIPAL: (Person Creating the Power of Attorney for Health Care)

 

Signature__________________________________________________

               «HusbandName»

 

13. STATEMENT OF WITNESSES: I know the princ [Portion Redacted - Included In Fully Licensed Version] lly and I believe him or her to be of sound mind and least 18 years of age. I believe that his or her execution of this power of attorney for health care is voluntary. I am at least 18 ye [Portion Redacted - Included In Fully Licensed Version] and am not related to the principal by blood, marriage or adoption. I am not a health care provider who is serving the principal at this time. [Portion Redacted - Included In Fully Licensed Version] best of my knowledge, I am not entitled to and do not have a claim on the principal's estate.

 

Witness #1:

 

Print Name: «Witness_1»  Date: _____/_____/ 200___

 

Address:                                                          

Signature:_______________________________________________________

 

Witness #2:

 

Print Name: «Witness_2»  Date: _____/_____/ 200___

 

Address:                                                         

 

Signature:______________________________________________________

 

14. STATEMENT OF HEALTH CARE AGENT: I understand «HusbandName» has designated me to be his health care agent if [Portion Redacted - Included In Fully Licensed Version] found to have incapacity and unable to make health care decisions himself. «HusbandName» has discussed his desires regarding health care decisions with me.

 

Print Name:  «WifeName» Date: _____/_____/ 200___ 

 

Address:                                                         

 

Signature:______________________________________________________

 

15. STATEMENT OF FIRST ALTERNATE HEALTH CARE AGENT: I understand that «HusbandName» has designated me to [Portion Redacted - Included In Fully Licensed Version] is health care agent if he is ever found to have incapacity and unable to make health care decisions himself and if the [Portion Redacted - Included In Fully Licensed Version] nated as health care agent is unable or unwilling to make those decisions.  «HusbandName» has discussed his or her desires regarding health care decisions with me.

 

Print Name: «HusbandHCPA_1»  Date: _____/_____/ 200___

 

Address:«HusbandHCPA_1_Add»  «HusbandHCPA_1_CSZ»

 

Telephone:«HusbandHCPA_1_Phone»

Signature:_______________________________________________________

 

16. STATEMENT OF SECOND ALTERNATE HEALTH CARE AGENT: I u [Portion Redacted - Included In Fully Licensed Version] tand that  «HusbandName» has designated me to be his health care agent if he is ever found to have incapacity and unable to make health care decisions himself and if [Portion Redacted - Included In Fully Licensed Version] erson designated as first alternate health care agent is unable or unwilling to make those decisions.  «HusbandName» has discussed his or her desires regarding health care decisions with me.

 

Print Name: «HusbandHCPA_2»  Date: _____/_____/ 200___

 

Address: «HusbandHCAP_2_Add»  «HusbandHCPA_2_CSZ»

 

Telephone: «HusbandHCPA_2_Phone»

 

Signature:_______________________________________________________

 

Failure to execute a power of attorney for health care

document under chapter [Portion Redacted - Included In Fully Licensed Version] Statutes

creates no presumption about the intent of any individual

with regard to his or her health care decisions.

 

This power of attorney for health care is executed as provided in chapter [Portion Redacted - Included In Fully Licensed Version] ues.