Advanced Directive
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7A
D
DVANCE
IRECTIVE
P
A
ART
A
H
C
A
PPOINTMENT OF
EALTH
ARE
GENT
(Optional Form)
(Cross through this whole part of the form if you do not want to appoint a health care agent to
make health care decisions for you. If you do want to appoint an agent, cross through any items
in the form that you do not want to apply.)
1.
I, ________________________________________________________________, residing
at _______________________________________________________________________
_______________________________________________________________________
appoint the following individual as my agent to make health care decisions for me:
________________________________________________________________________
______________________________________________________________________
(Full Name, Address, and Telephone Number of Agent)
Optional: If this agent is unavailable or is unable or unwilling to act as my agent, then I
appoint the following person to act in this capacity:
________________________________________________________________________
______________________________________________________________________
(Full Name, Address, and Telephone Number of Back-up Agent)
2.
In accordance with the Health Insurance Portability and Accountability Act (“HIPAA”) , a
health care agent is a personal representative and is entitled to request and receive protected
health information.
3.
My agent has full power and authority to make health care decisions for me, including the
power to:
A.
In accordance with HIPAA and as my personal representative, request, receive, and
review any information, oral or written, regarding my physical or mental health,
including, but not limited to, medical and hospital records, and other protected
health information, and consent to disclosure of this information;
B.
Employ and discharge my health care providers;
C.
Authorize my admission to or discharge from (including transfer to another facility)
any hospital, hospice, nursing home, adult home, or other medical care facility; and
D.
Consent to the provision, withholding, or withdrawal of health care, including, in
appropriate circumstances, life sustaining procedures.
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