Fill and Sign the Medical Directive Form

MILITARY ADVANCE MEDICAL DIRECTIVE STATE OF ____________________ COUNTY OF ____________________ This is a MILITARY ADVANCE MEDICAL DIRECTIVE prepared pursuant to Title10, United States Code, Section 1044(c). It was prepared by an attorney who was authorized to provide legal assistance for an individual who was eligible to receive legal assistance. Federal law exempts this advance medical directive from any requirement of form, substance, formality, or recording that is provided for advance medical directives under the laws of a State. Federal law specifies that this advance medical directive shall be given the same legal effect as an advance medical directive prepared and executed in accordance with the laws of the State concerned. It is suggested for use by any person authorized to receive legal assistance from the military service in accordance with federal or state law, who by these presents represents and warrants that he is so eligible. Any person to whom this form is presented may conclusively rely on the authority purportedly granted hereunder. BE IT KNOWN on this ______ day of ____________________ , 20 ______ , before me, an attorney authorized to render legal assistance to persons eligible for legal assistance under the provisions of 10 U.S.C. § 1044 or the regulations of the Department of Defense, personally came and appeared _____________________________ , who declared that he is a member of the _____________________________ , a branch of the military designated in R.S. 40:1299.60, or is otherwise included thereunder, and did execute and sign the following declaration: I, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below and do hereby declare: If at any time I should have an incurable injury, disease or illness, or be in a continual profound comatose state with no reasonable chance of recovery, certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures, including hydration and sustenance, be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care. [Optional:] In the absence of my ability to give further directions regarding the use of such life-sustaining procedures, I authorize _____________________________ , caretaker, to make treatment decisions on my behalf and I have discussed my desires concerning terminal care with this person and I trust his/her judgment on my behalf.] Should my caretaker be an absent person or cease or otherwise fail to act or if a caretaker has not been named in this declaration, it is my intention that this declaration be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. 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 disclosure of this information; and (4) Consent to the donation of any of my organs for medical purposes. B. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. 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 identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent 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. I understand the full import of this declaration and I am emotionally and mentally competent to make this advance medical directive. Signed: ____________________ City, County, and State of Residence _____________________________ ___________________________ (SIGNATURE OF ATTORNEY)