Advance Health Care Directive Form Page 2
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2PART 2: HEALTH-CARE POWER OF ATTORNEY AGENT’S AUTHORITY AND OBLIGATION
My agent shall make health-care decisions for me in accordance with my best interests and wishes so far as they are known.
In determining my best interest, my agent shall consider my personal values. If a guardian of my person needs to be appoint-
ed for me by a court, I nominate my agent. I designate the following individual as my agent. He/she may make all health-
care decisions for me if I am unable or unwilling to make them for myself unless I direct otherwise:
Name of Agent (Spouse, adult child, friend or other trusted person)
Relationship
Street Address
City
State
Zip
Home Phone
Work Phone
E-mail
If my agent is not available, I designate the following person as my alternative agent:
Name of Alternate Agent (Spouse, adult child, friend or other trusted person)
Relationship
Street Address
City
State
Zip
Home Phone
Work Phone
E-mail
____ My agent may make all health-care decisions for me. OR
____ My agent may make all health-care decisions for me except: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
____ My agent’s authority becomes effective when my primary physician determines that I am unable to make health-care
decisions.OR
____ My agent’s authority to make health-care decisions for me takes effect immediately.
YOUR NAME:
Print Your Full Name
Your Signature
Date
WITNESSES: CHOOSE EITHER OPTION 1 OR 2, NOT BOTH.
Important: Witnesses cannot be your health-care agent, a health-care provider or an employee of a health-care facility. One
witness cannot be a relative or have inheritance rights.
OPTION 1: W
ITNESSES
Witness #1 Print Name
Witness Signature
Date
Address
City
State
Zip Code
Witness #2 Print Name
Witness Signature
Date
Address
City
State
Zip Code
OPTION 2: Notary Public
State of Hawai‘i, _____________ (County)
On this _______ day of ___________, in the year _______, before me, ______________________________, (insert name of
notary public) appeared ______________________________, personally known to me (or proved to me on the basis of satis-
factory evidence) to be the person whose name is subscribed to this instrument and acknowledged that he or she executed it.
My Commission Expires:______________
A copy has the same effect as the original.
Developed by the Executive Office on Aging,
State of Hawai‘i – Revised September 2003.
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