The Minnesota Health Care Directive Page 10
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16My primary
I appoint:
Agent’s name: ____________________________________________
health care
Address: _________________________________________________
agent
________________________________________________________
Home phone: (###) ___________________
Work phone: (###) ___________________
My first
Agent’s name: ____________________________________________
alternate
Address: _________________________________________________
health care
________________________________________________________
agent
Home phone: (###) ___________________
Work phone: (###) ___________________
My second
Agent’s name: ____________________________________________
alternate
Address: (3 lines) __________________________________________
health care
________________________________________________________
agent
Home phone: (###) ___________________
Work phone: (###) ___________________
(If needed)
I have named as my agent a health care provider, or employee of a
Reasons for
health care provider, who is currently or might be providing direct care
naming
to me when decisions are needed.
health care
____That person is related to me by blood, marriage, registered
provider
domestic partnership, or adoption.
____My reasons for wanting to appoint that person as my agent are:
________________________________________________________
________________________________________________________
If I am unable to decide or speak for myself, my agent has the power to:
Powers of my
• Consent to, refuse, or withdraw any health care, treatment, service, or
agent
procedure
• Stop or not start health care which is keeping or might keep me alive
• Choose my health care providers
• Choose where I live when I need health care and what personal
security measures are needed to keep me safe.
• Obtain copies of my medical records and allow others to see them.
Minnesota Health Care Directive / 2 of 4 pages
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