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Health Care Directive

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Health Care Directive

File Type: Word      Price: $9.99        

                                                                                        

Summary: An advance directive allows you to give instructions to your health care providers and your family regarding your health care decisions should you become incapacitated. Usually, advance health care directives will only go into effect if you can't make your own health care decisions. Until such an time, you can continue to give directions to your health care providers even though you have an advance directive.


Health care providers are required under the federal Patient Self Determination Act to give patients information about their rights to make their own health care decisions. This very thorough form allows you to document your own directive so that your doctors and family make your desired decisions.

 

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ADVANCE HEALTH CARE DIRECTIVE

MY NAME IS                                                                                                            .

PART 1:  HEALTH CARE POWER OF ATTORNEY

DESIGNATION OF AGENT:  

I designate the following individual as my agent to make health care decisions for me:

                                                                                                                                                (Name and relationship of individual designated as health care agent)                                                                                                                                               

(Address)  (City) (State)    (Zip code) (Home phone) (Work phone) (E-Mail)

If I revoke my agent’s authority or if my agent is not willing, able, or reasonably available to make decisions for me, I designate the following individual as my alternate agent:

                                                                                                                                              

(Name and relationship of individual designated as alternate health care agent)

                                                                                                                                               

(Address) (City) (State)     (Zip code)  (Home phone)  (Work phone) (E-Mail)

WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE:

My agent’s authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box.

____ c  If I mark this box, my agent’s authority to make health care decisions for me takes effect immediately.  However, I always retain the right to make my own decisions about my health care and to revoke this authority as long as I am mentally capacitated.  

AGENT'S AUTHORITY AND OBLIGATION:

I intend my agent’s authority to be as broad as possible subject only to any instructions and limitations I may state in Part 2 of this form or as I may otherwise provide orally or in writing. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest.  In determining my best interest, my agent shall consider my personal values to the extent known to my agent.  If a guardian of my person needs to be appointed for me by a court, I nominate my agent.  

PART 2:  INDIVIDUAL INSTRUCTIONS FOR HEALTH CARE

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