Fill and Sign the Power Attorney Health Form

DURABLE POWER OF ATTORNEY FOR HEALTH CARE THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for y ou when you are no longer capable of making them yourself. Health care means any treatm ent, service or procedure to maintain, diagnose or treat your physical or mental condition. Your age nt, therefore, can have the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatme nt and may make decisions about withdrawing or withholding life-sustaining treat ment. Your agent cannot consent or direct any of the following: commitment to a st ate institution, sterilization, or termination of treatment if you are pregnant and if the withdrawal of that treatment is deemed likely to terminate the pregnancy unless the fa ilure to withhold the treatment will be physically harmful to you or prolong severe pain which c annot be alleviated by medication. You may state in this document any treatment you do not desire, except as stated above, or treatment you want to be sure you receive. Your agent's authority will begin when your doctor certifies that you lack the capacity to make health care deci sions. If for moral or religious reasons you do not wish to be treated by a doctor or examined by a doct or for the certification that you lack capacity, you must say so in the docum ent and name a person to be able to certify your lack of capacity. That person may not be your agent or alternate agent or any person ineligible to be your agent. You may attach additional pages if you need more space to complete your statement. If you want to give your agent authority to withhold or withdraw the artifi cial providing of nutrition and fluids, your document must say so. Otherwise, your agent will not be able to direct that. Under no conditions will your agent be able to direct the wi thholding of food and drink for you to eat and drink normally. Your agent will be obligated to follow your instructions when making decisi ons on your behalf. Unless you state otherwise, your agent will have the same authori ty to make decisions about your health care as you would have had if made consistent with state law. It is important that you discuss this document with your physician or other he alth care providers before you sign it to make sure that you understand the nature an d range of decisions which may be made on your behalf. If you do not have a physician, y ou should talk with someone else who is knowledgeable about these issues and can answer your questions. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer t o explain it to you. The person you appoint as agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your physician, or an employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your agent or as your health or residential care provider; the law does not permi t a person to do both at the same time. You should inform the person you appoint that you want him or her to be your health care agent. You should discuss this document with your agent and your physician and give each a signed copy. You should indicate on the document itself the pe ople and institutions who will have signed copies. Your agent will not be liable for health care decisions made in good faith on your behalf. Even after you have signed this document, you have the right to make heal th care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care provider orally or in writing. This document may not be changed or modified. If you want to make changes i n the document you must make an entirely new one. You should consider designating an alternate agent in the event that your a gent is unwilling, unable, unavailable, or ineligible to act as your agent. Any a lternate agent you designate will have the same authority to make health care decisions for you. 1. DESIGNATION OF HEALTH CARE AGENT. I, ______________________________________________________________________ (Insert your name and address) do hereby designate and appoint _____________________________________________ (Insert name, address, and telephone number of one individual only as your agent to make health care decisions for you. None of the following may be designated as your agent: (1) your treating health care provider, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility, or (4) a nonrelative employee of an operator of a community care facility). as my attorney in fact (agent) to make health care decisions for me as authorized in this document. 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 condition. 2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a durable power of attorney for health care . This power of attorney shall not be affected by my subsequent incapacity. 3. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any li mitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions f or myself if I had the capacity to do so. In exercising this authority, my agent shall ma ke health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires concerning obt aining or refusing or withdrawing life-prolonging care, treatment, services, and procedures. (If you want to limit the authority of your agent 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 health 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 life-prolonging care, treatment, services, and procedures. You can also include a statement of your desires concerning other matters relating to your health care. You can also make your desires known to your agent by discussing your desires with your agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit in any other way the authority given your agent by this document, you should state the limits in the space below. If you do not state any limits, 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 under this durable power of attorney for health care, my agent shall act consistently with my desires as stated. Additional sta tement of desires, special provisions, and limitations: [None or State limitations] (You may attach additional pages if you need more space to complete your statement. If you attach additional pages, you must date and sign each of the additional pages at the same time you date and sign this document.) 5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO M Y PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my agent has the power and authority to do all of the following: (a) Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records. (b) Execute on my behalf any releases or other documents that may be required in order to obtain this information. (c) Consent to the disclosure of this information. (d) 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 limitations in paragraph 4 ("Statement of Desires, Special Provisions, and Limitations") above.) 6. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary t o implement the health care decisions that my agent is authorized by t his document to make, my agent has the power and authority to execute on my behalf all of the following: (a) Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice." (b) Any necessary waiver or release from liability required by a hospita l or physician. 7. DESIGNATION OF ALTERNATE AGENTS. (You are not required to designate any alternate agents but you may do so. Any alternate agent you designate will be able to make the same health care decisions as the agent you designated in paragraph 1, above, in the event that agent is unable or ineligible to act as your agent. If the agent you designated is your spouse, he or she becomes ineligible to act as your agent if your marriage is dissolved.) If the person designated as my agent in paragraph 1 is not available or becomes ineligible to act as my agent to make a health 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 authori ty to act as my agent to make health care decisions for me, then I desig nate and appoint the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below: A. First Alternate Agent _____________________________________________________________________ (Insert name, address, and telephone number of first alternate agent) B. Second Alternate Agent _____________________________________________________________________ (Insert name, address, and telephone number of second alternate agent) 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 Power of Attorney) I sign my name to this Durable Power of Attorney for Health Care on ___________________ at _________________________________________________, (Date) (City) (State) _______________________________________________________________________ (You sign here) STATEMENT OF WITNESSES (This document should be witnessed by two qualified adult witnesses. None of the following may be used as a witness: (1) a person you designate as your agent or alternate agent, (2) a health care provider, (3) an employee of a health care provider, (4) the operator of a community care facility, (5) an employee of an operator of a community care facility, (6) your spouse, or (7) your lawful heirs or beneficiaries named in your will or a deed. At least one of the witnesses must make the additional declaration set out following the place where the witnesses sign.) The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I did not sign the declarant's signature above for or at the direction of the dec larant. I am not a parent, spouse, or child of the declarant. I am not entitled to a ny part of the declarant's estate or directly financially responsible for the declarant's medical c are. I am competent and at least eighteen (18) years of age. Witness Signature: ________________________________________________________ Print name: ______________________________________________________________ Date: _______________________ Residence address: _______________________ Signature: _______________________________________________________________ Print name: ______________________________________________________________ Date: _______________________ Residence address: _______________________ This Power of Attorney will not be valid without your signature and is notarized. NOTARY State of Indiana County of ___________________ On this _____ day of _______________ 20___ before me personally appeared ________________________________________________________________________ full name of signer of instrument) to me known (or proved to me on basis of sat isfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed it. I declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence. _________________________________________________ Notary Print Name of Notary: _______________________________ My Commission Expires: ______________________