Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form (Page 7 of 9) in pdf

Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form Page 7

Designation of Health Care Surrogate

Name: ______________________________________________________

In the event that I have been determined to be incapacitated to provide informed consent for medical

treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care

decisions:

Name ________________________________________________________

Street Address _________________________________________________

City ________________________ State __________ Phone _____________

Phone: ______________

If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate

surrogate:

Name ________________________________________________________

Street Address _________________________________________________

City ________________________ State __________ Phone _____________

I fully understand that this designation will permit my designee to make health care decisions and to

provide, withhold, or withdraw consent on my behalf; or apply for public benefits to defray the cost of

health care; and to authorize my admission to or transfer from a health care facility.

Additional instructions (optional):

_______________________________________________________________________________

I further affirm that this designation is not being made as a condition of treatment or admission to a health

care facility. I will notify and send a copy of this document to the following persons other than my

surrogate, so they may know who my surrogate is.

Name ______________________________________________________

Signed _____________________________________________________

Date _________________________

Witnesses

1. ________________________________________

2. ________________________________________

At least one witness must not be a husband or wife or a blood relative of the principal.

Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form Page 7