Hawaii Advance Health Care Directive Page 2
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8health care.
After completing this form, sign and date the form at the end and have the form
witnessed by one of the two alternative methods listed below. Give a copy of the signed
and completed form to your physician, to any other health-care providers you may have,
to any health-care institution at which you are receiving care, and to any health-care
agents you have named. You should talk to the person you have named as agent to make
sure that he or she understands your wishes and is willing to take the responsibility.
You have the right to revoke this advance health-care directive or replace this form at any
time.
PART 1
DURABLE POWER OF ATTORNEY FOR HEALTH-CARE DECISIONS
(1) DESIGNATION OF AGENT: I designate the following individual as my agent to
make health-care decisions for me:
(name of individual you choose as agent)
(address)
(city)
(state) (zip code)
(home phone)
(work phone)
OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or
reasonably available to make a health-care decision for me, I designate as my first
alternate agent:
(name of individual you choose as first alternate agent)
(address)
(city)
(state) (zip code)
(home phone)
(work phone)
OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is
willing, able, or reasonably available to make a health-care decision for me, I designate
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