Health Care Directive (Living Will) Page 2
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1
2HEALTH CARE (MEDICAL) POWER OF ATTORNEY
WITH MENTAL HEALTH AUTHORITY
It is important to choose someone to make healthcare decisions for you when you cannot. Tell the person (agent) you
choose what you would want. The person you choose has the right to make any decision to ensure that your wishes
are honored. If you DO NOT choose someone to make decisions for you, write NONE in the line for the agent’s name.
I,
, as principal, designate
as my agent for all matters relating to my health (including
mental health) and including, without limitation, full power to give or refuse consent to all medical, surgical, hospital and
related health care. This power of attorney is effective on my inability to make or communicate health care decisions. All
of my agent's actions under this power during any period when I am unable to make or communicate health care
decisions or when there is uncertainty whether I am dead or alive have the same effect on my heirs, devisees and
personal representatives as if I were alive, competent and acting for myself.
By initialing here, I specifically consent to giving my agent the power to admit me to an inpatient or partial
psychiatric hospitalization program if ordered by my physician.
By initialing here, this Health Care Directive including Mental Health Care Power of Attorney may not be revoked
if I am incapacitated.
Print agent ADDRESS and PHONE:
If my agent is unwilling or unable to serve or continue to serve, I hereby appoint:
as my agent.
Print alternate agent ADDRESS and PHONE:
I intend for my agent to be treated as I would regarding the use and disclosure of my individually identifiable health
information or other medical records. This release authority applies to any information governed by the Health Insurance
Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1420D and 45 CFR 160-164.
SIGN HERE for the Health Care (Medical) Power of Attorney and/or the Health Care Directive forms
Please ask one person to witness your signature who is not related to you or financially connected to you or your estate.
Signature
Date
The above named person is personally known to me, and I believe him/her to be of sound mind and to have
completed this document voluntarily. I am at least 18 years old, not related to him/her by blood, marriage or
adoption, and not an agent named in this document. I am not to my knowledge a beneficiary of his/her will or any
codicil, and I have no claim against his/her estate. I am not directly involved in his/her health care.
Witness
Date
This document may be notarized instead of witnessed.
On this
day of
, in the year of
, personally appeared before me the
person signing, known by me to be the person who completed this document and acknowledged it as his/her free act and
deed. IN WITNESS THEREOF, I have set my hand and affixed my official seal in the County of
,
State of
, on the date written above.
Notary Public
FOR MORE INFORMATION CONTACT HEALTH CARE DECISIONS, (602) 222-2229 OR
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