Living Will and Durable Power of Attorney for Health Care

In the case of wanting to grant Durable Power of Attorney to another person for making decisions related to you or your health, the following form has to be completed and submitted.

Extracted Text for Proper Search

LIVING 	W	ILL AND 	D	URABLE 	P	OWER OF 	A	TTORNEY FOR 	H	EALTH 	C	ARE	 	
 
 
Date of Directive:       	
 
 
Name of person executing Directive:        	
 
 
Address of person executing Directive:        
 
 
             
 
   
A Living Will	
 
A Directive to Withhold or to Provide Treatment	
 
 
1.  I willfully and voluntarily  make known my desire that my life shall not be 
prolonged artificially under  the circumstances set forth below.  This Directive 
shall be effective only if I am unable to communicate my instructions and: 
 
  a.  I have an incurable or irreversible injury, disease, illness or condition, and  a medical doctor who has ex amined me has certified: 
  1.  That such injury, disease, ill ness or condition is terminal; and 
2.  That the application of artifici al life-sustaining procedures would 
serve only to prolong artificially my life; and 
3.  That my death is imminent, whether or not artificial  life-sustaining 
procedures are utilized. 	
 	
OR 	
 
  b.    I have been diagnosed as being  in a persistent vegetative state. 
 
In such event, I direct that the following marked expression of my intent be followed and 
that I receive any medical treatment or ca re that may be required to keep me free of 
pain or distress. 
 
Check  one	
 box and initial the line after such box: 	
 
 
†	  
  	 I direct that all medical treat
ment, care, and procedures necessary 
to restore my health and sustain my lif e be provided to me.  Nutrition and 
hydration, whether artificial or non-arti ficial, shall not be withheld or withdrawn 
from me if I would likely di e primarily from malnutrition or dehydration rather than 
from my injury, disease, illness or condition. 
 	
 
OR

†	  
  	 I direct that all medical treatment, care and procedures, including 
artificial life-sustaining procedures,  be withheld or withdrawn, except that 
nutrition and hydration, whether  artificial or non-artificial shall not be withheld or 
withdrawn from me if, as a result, I would  likely die primarily from malnutrition or 
dehydration rather than from my injury, di sease, illness or condition, as follows: 
 
(If none of the following boxes are che cked and initialed, then both nutrition and 
hydration, of any nature, w hether artificial or non-artifi cial, shall be administered.) 
 
Check  one	
 box and initial the line after such box: 
 
 	
†	    	 A.  Only hydration of any natur e, whether artificial or non-
artificial, shall be administered. 
 	
†	    	 B.  Only nutrition, of any natur e, whether artificial or non-
artificial, shall be administered. 
 	
†	    	 C.  Both nutrition and hydration,  of any nature, whether artificial 
or non-artificial shall be administered. 
 	
OR	 	
 	
 
†	   
  	 I direct that all m
edical treatment, care and procedures be withheld 
or withdrawn, including withdraw al of the administration of artificial nutrition and 
hydration.  
 
 
2.  If I have been diagnosed as pregnant, this  Directive shall have no force during 
the course of my pregnancy. 
 
3.  I understand the full importance of this  Directive and am mentally competent to 
make this Directive.  No participant in the making of this Directive or in its being 
carried into effect shall be held responsib le in any way for complying with my 
directions. 
 
4. Check  one	
 box and initial the line after such box: 
 	
 	
Living Will and Durable Power of  Attorney for Health Care 
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†	  
  	 I have discussed these decisions with my physician and have also 
completed a Physician Orders for Scope of  Treatment (POST) form that contains 
directions that may be more specific than,  but are compatible with, this Directive. 
I hereby approve of those orders and incorporate t hem herein as if fully set forth. 
 
 	
OR	 
 	
†	   
  	 I have not completed a Physician
 Orders for Scope of Treatment 
(POST) form.  If a POST form is later signed  by my physician, then this living will 
shall be deemed modified to be compatible  with the terms of the POST form. 
 
  A Durable Power of Atto rney for Health Care	
 
 
1.  DESIGNATION OF HEALTH CARE AGENT   
None of the following may be designated as your agent:   
(1) your treating health care provider; 
(2) a non-relative employee of your  treating health care provider; 
(3) an operator of a community care facility; or 
(4) a non-relative employee of an operat or of a community care facility. 
 
If the agent or an alternate agent designated in  this Directive is my spouse, and our 
marriage is thereafter dissolved, such  designation shall be thereupon revoked.  
 
I do hereby designate and appo int the following individual as my attorney in fact (agent) 
to make health care decisions for  me as authorized in this Directive. 
 
(Insert name, address and tel ephone number of one individu al only as your agent to 
make health care decisions for you.) 
 
Name of Health Care Agent:         	
 
   
Address of Health Care Agent:         
 
 
Telephone Number of Health Care Agent:            
 
 
For the purposes of this Directive, "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 i ndividual's physical condition. 
 
 
 	
 	
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2.  CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE 
 
By this portion of this Directive, I create a  durable power of attorney for health care.  
This power of attorney shall not be affect ed by my subsequent incapacity.  This power 
shall be effective only when I am unable to communicate rationally. 
 
 
3.  GENERAL STATEMENT OF AUTHORITY GRANTED 
 
I hereby grant to my agent full power and author ity to make health care decisions for me 
to the same extent that I could make such  decisions for myself if I had the capacity to do 
so.  In exercising this authority, my agent shall make health care decisions that are 
consistent with my desires as stated in th is Directive or otherwise made known to my 
agent including, but not limit ed to, my desires concerning obtaining or refusing or 
withdrawing artificial life-sustaining care,  treatment, services and procedures, including 
such desires set forth in a  living will, Physician Orders fo r Scope of Treatment (POST) 
form, or similar document  executed by me, if any. 
 
(If you want to limit the authority of your ag ent to make health care decisions for you, 
you can state the limitations in  paragraph 4, "Statement of Desires, Special Provisions, 
and Limitations", below.  You can indicate your  desires by including a statement of your 
desires in the same paragraph.) 
 
 
4.  STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS 
 
(Your agent must make healt h care decisions that are consistent with your known 
desires.  You can, but are not required to, state your desires in the space provided 
below.  You should consider whether you want  to include a statement of your desires 
concerning artificial life-sustaining care,  treatment, services and procedures.  You can 
also include a statement of y our desires concerning other matte rs relating to your health 
care, including a list of one or  more persons whom you desi gnate to be able to receive 
medical information about you and/or to be allo wed to visit you in a medical institution. 
You can also make your desires known to  your agent by discussing your desires with 
your agent or by some other means.  If ther e are any types of treatment that you do not 
want to be used, you should state them in t he space below. If you want to limit in any 
other way the authority given yo ur agent by this Directive, you should state the limits in 
the space below. If you do not state any lim its, your agent will have broad powers to 
make health care decisions for you, except to  the extent that there are limits provided by 
law.) 
 
In exercising the authority und er this durable power of attorney for health care, my 
agent shall act consistently with my desires as  stated below and is subject to the special 
provisions and limitations stated in my Phys ician Orders for Scope of Treatment (POST) 
form, a living will, or similar  document executed by me, if any .  Additional statement of 
desires, special provisions, and limitations:

(You may attach additional pages or documents if you need  more space to complete 
your statement.) 
 
 
5.  INSPECTION AND DISCLOSURE OF  INFORMATION RELATING TO MY 
PHYSICAL OR MENTAL HEALTH 
 
 
A.  General Grant of Power and Authority 
  Subject to any limitations in this  Directive, my agent has the power and 
authority to do all of the following: 
  (1) Request, review and receive any  information, verbal or written, 
regarding my physical or mental health  including, but not limited to, 
medical and hospital records; 
(2) Execute on my behalf any releases  or other documents that may be 
required in order to obtain this information; 
(3) Consent to the disclosur e of this information; and 
(4) Consent to the donation of any of  my organs for medical purposes. 
 
(If you want to limit the authority of your  agent to receive and disclose information 
relating to your health, you must state the li mitations in paragraph 4, "Statement of 
Desires, Special Provisi ons, and Limitations", above.) 
  
 
B.  HIPAA Release Authority 
 	
 	
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My agent shall be treated as I would be wit h respect to my rights regarding the 
use and disclosure of my individually i dentifiable health information or other 
medical records. This release authorit y applies to any information governed by 
the Health Insurance Portability and A ccountability Act of 1996 (HIPAA), 42 
U.S.C. 1320d and 45 CFR 160  through164.  I authorize any physician, health 
care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or 
other covered health care provider, any  insurance company, and the Medical 
Information Bureau, Inc. or other health care clearinghouse that has provided 
treatment or services to me, or that has  paid for or is seeking payment from me 
for such services, to give, disclose and  release to my agent, without restriction, 
all of my individually i dentifiable health information an d medical records regarding 
any past, present or future  medical or mental health condition,  including  all  
information relating to the diagnosis of HI V/AIDS, sexually transmitted diseases, 
mental illness, and drug or  alcohol abuse. The authori ty given my agent shall 
supersede any other agreement that  I may have made with my health care 
providers to restrict access to or disclosu re of my individually identifiable health 
information.  The authority given my age nt has no expiration date and shall 
expire only in the event that I revoke the  authority in writing and deliver it to my 
health care provider. 
 
 
6. SIGNING DOCUMENTS,  WAIVERS, AND RELEASES 
 
Where necessary to implement the health care  decisions that my agent is authorized by 
this Directive to make, my agent has the powe r and authority to execute on my behalf 
all of the following: 
  (a)  Documents titled, or purporting to  be, a "Refusal to Permit Treatment" 
and/or a "Leaving Hospital Against Medical Advice"; and 
(b)  Any necessary waiver or release fr om liability required by a hospital or 
physician. 
 
  
7.  DESIGNATION OF ALTERNATE AGENTS 
 
(You are not required to des ignate any alternate agents but you may do so. Any 
alternate agent you designate wi ll be able to make the same health care decisions as 
the agent you designated in pa ragraph 1 above, in the event that agent is unable or 
ineligible to act as your agen t.  If an alternate agent you de signate is your spouse, he or 
she becomes ineligible to act as your agent  if your marriage is thereafter dissolved.) 
 
If the person designated as my agent in par agraph 1 is not available or becomes 
ineligible to act as my agent to make a heal th care decision for me or loses the mental 
capacity to make health care decisions for me, or if I revoke that  person's appointment 
or authority to act as my agent to make he alth care decisions for me, then I designate 
and appoint the following persons  to serve as my agent to make health care decisions 
for me as authorized in this Directive, such  persons to serve in the order listed below:

Living Will and Durable Power of Attorney for Health Care 
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A.  First Alternate Agent 	
 	
Name:          	 	
 	
Address:         	 	
 
            	 
 	
 	
  Telephone Number:        	 
  B.  Second Alternate Agent 	
 	
Name:          	 	
 	
Address:         	 	
 
            	 
 	
 	
  Telephone Number:        	 
  C.  Third Alternate Agent 	
 	
Name:          	 	
 	
Address:         	 	
 
            	 
 	
 	
  Telephone Number:        	 
 
 
8.  PRIOR DESIGNATIONS REVOKED 
 
I revoke any prior durable power  of attorney for health care. 
 
DATE AND SIGNATURE OF PRINCIPAL 
 
(You must date and sign this Living Will and Durable Power of Attorney for Health 
Care.) 
 
I sign my name to this Statutory Form Li ving Will and Durable Power of Attorney for 
Health Care on the date set forth  at the beginning of this Form at: 
 
 
 
             	
 
(Signature)          (City, State)