Fillable Durable Power Of Attorney For Health Care printable pdf download

Durable Power of Attorney for Health Care

This document has been reprinted with permission from the Washington State Medical Association.

This form is not a substitute for the advice of an attorney. Any legal question you may have about

a Durable Power of Attorney for Health Care should be directed to an attorney .

Notice to Person Executing This Document

This is an important legal document . Before executing this document you should know these facts:

This document gives the person you designate as

consent , or to withdraw informed consent to any

your Health Care Agent the power to make MOST

care, treatment, service, or procedure to maintain,

health care decisions for you if you lose the capabil-

diagnose, or treat a physical or mental condition .

ity to make informed health care decisions for your-

You can limit that right in this document if you

self . This power is effective only when you lose the

choose .

capacity to make informed health care decisions for

When exercising his or her authority to make health

yourself . As long as you have the capacity to make

care decisions for you when deciding on your behalf,

informed health care decisions for yourself, you

the Health Care Agent will have to act consistent

retain the right to make all medical and other health

with your wishes, or if they are unknown, in your

care decisions .

best interest . You may make your wishes known to

the Health Care Agent by including them in this

You may include specific limitations in this docu-

document or by making them known in another

ment on the authority of the Health Care Agent to

manner .

make health care decisions for you .

When acting under this document the Health Care

Subject to any specific limitations you include

Agent GENERALLY will have the same rights that

in this document, if you do lose the capacity to

you have to receive information about proposed

make an informed decision on a health care mat-

health care, to review health care records, and to

ter, the Health Care Agent GENERALLY will

consent to the disclosure of health care records .

be authorized by this document to make health

care decisions for you to the same extent as you

could make those decisions yourself, if you had

the capacity to do so . The authority of the Health

Care Agent to make health care decisions for you

GENERALLY will include the authority to give

informed consent, to refuse to give informed

1. Creation of Durable Power of Attorney for Health Care

I intend to create a power of attorney (Health Care Agent) by appointing the person or persons designated

herein to make health care decisions for me to the same extent that I could make such decisions for myself if I

was capable of doing so, as recognized by RCW 11 .94 .010 . This designation becomes effective when I cannot

make health care decisions for myself as determined by my attending physician or designee, such as if I am

unconscious, or if I am otherwise temporarily or permanently incapable of making health care decisions . The

Health Care Agent’s power shall cease if and when I regain my capacity to make health care decisions .

2. Designation of Health Care Agent and Alternate Agents

If my attending physician or his or her designee determines that I am not capable of giving informed consent to

health care, I ____________________________ designate and appoint:

(Name)

(Address)

(City)

(State) (Zip)

(Phone)

as my attorney-in-fact (Health Care Agent) by granting him or her the Durable Power of Attorney for Health

Care recognized in RCW 11 .94 .010 and authorize her or him to consult with my physicians about the possibility

of my regaining the capacity to make treatment decisions and to accept, plan, stop, and refuse treatment on my

behalf with the treating physicians and health personnel .

Durable Power Of Attorney For Health Care

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