PART 1. DURABLE HEALTH CARE POWER OF ATTORNEY

1. Information about me (the Principal):

Name: [PRINCIPAL’S NAME] Age: [#]
Address: [ADDRESS] Date of Birth: [DAY] day of [MONTH], [YEAR]
Telephone: [PHONE]

2. Selection of my health care representative and alternate: (also called an “agent” or “surrogate”)

I choose the following person to act as my representative to make mental health care decisions for me:

Name: [AGENT’S NAME] Home Phone: [PHONE]
Address: [ADDRESS] Work Phone: [PHONE]
Cell Phone: [PHONE]

3. I AUTHORIZE if I am unable to make medical care decisions for myself:

I authorize my health care representative to make health care decisions for me when I cannot make or communicate my own health care decisions due to mental or physical illness, injury, disability, or incapacity. I want my representative to make all such decisions for me except those decisions that I have expressly stated in Part 4 below that I do not authorize him/her to make. If I am able to communicate in any manner, my representative should discuss my health care options with me. My representative should explain to me any choices he or she made if I am able to understand. I further authorize my representative to have all access to and copies of my “personal protected health care information and medical records”. This appointment is effective unless and until it is revoked by me or by an order of a court.

4. DECISIONS I EXPRESSLY DO NOT AUTHORIZE my Representative to make for me:

I do not want my representative to make the following health care decisions for me:

[DESCRIBE OR WRITE IN “NOT APPLICABLE”]

5. My specific desires about autopsy:

[INITIALS] – Upon my death I DO NOT consent to a voluntary autopsy.
[INITIALS] – Upon my death I DO consent to a voluntary autopsy.
[INITIALS] – My representative may give or refuse consent for an autopsy

6. About a Living Will

[INITIALS] A. I have SIGNED AND ATTACHED a completed Living Will in addition to this Durable Health Care Power of Attorney to state decisions I have made about end of life health care if I am unable to communicate or make my own decisions at that time.
[INITIALS] B. I have NOT SIGNED a Living Will.

7. About a Prehospital Medical Care Directive or Do Not Resuscitate Directive

[INITIALS] A. I and my doctor or health care provider HAVE SIGNED a Prehospital Medical Care Directive or a Do Not Resuscitate Directive on Paper with ORANGE background in the event that 911 of Emergency Medical Technicians or hospital emergency personnel are called and my heart or breathing has stopped.
[INITIALS] B. I have NOT SIGNED a Prehospital Medical Care Directive or Do Not Resuscitate Directive.

8. HIPAA WAIVER OF CONFIDENTIALITY FOR MY AGENT/REPRESENTATIVE

[INITIALS] I intend for my agent to be treated as I would with respect to my rights regarding the use and disclosure of my individually identifiable health information or medical records. This release authority applies to information governed by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 42 USC 1320d, 45 CFR 160- 164.

PART 2. DURABLE MENTAL HEALTH CARE POWER OF ATTORNEY

1. Information about me (the Principal):

Name: [PRINCIPAL’S NAME] Age: [#]
Address: [ADDRESS] Date of Birth: [DOB]
Telephone: [PHONE]

2. Selection of my health care representative and alternate: (also called an “agent” or “surrogate”)

I choose the following person to act as my representative to make mental health care decisions for me:

Name: [AGENT’S NAME] Home Phone: [PHONE]
Address: [ADDRESS] Work Phone: [PHONE]
Cell Phone: [PHONE]

3. Mental heal treatments that I AUTHORIZE if I am unable to make decisions for myself:

Here are the mental health treatments I authorize my mental health care representative to make on my behalf if I become incapable of making my own mental health care decisions due to mental or physical illness, injury, disability, or incapacity. If my wishes are not clear from this Durable Mental Health Care Power of Attorney or are not otherwise known to my representative, my representative will, in good faith, act in accordance with my best interests. This appointment is effective unless and until it is revoked by me or by an order of a court. My representative is authorized to do the following which I have initialed or marked:

☐ – A. About my records: To receive information regarding mental health treatment that is proposed for me and to receive, review, and consent to the disclosure of any of my medical records related to that treatment.
☐ – B. About medications: To consent to the administration of any medications recommended by my treating physician.
☐ – C. About a structured treatment setting: To admit me to a structured treatment setting with 24hour-a-day supervision and an intensive treatment program licensed by the Department of Health Services, which is called an inpatient psychiatric facility.
☐ – D. Other: [DESCRIBE]

4. Durable mental health treatments that I expressly DO NOT AUTHORIZE if I am unable to make decisions for myself:

[EXPLAIN OR WRITE “NONE”]

5. Revocability of this Durable Mental Health Care Power of Attorney: This mental health care power of attorney or any portion of it may not be revoked and any designated agent may not be disqualified by me during times that I am found to be unable to give informed consent. However, at all other times I retain the right to revoke all or any portion of this mental health care power of attorney or to disqualify any agent designated by me in this document.

6. Additional information about my mental health care treatment needs (consider including mental or physical health history, dietary requirements, religious concerns, people to notify and any other matters that you feel are important):

[ADDITIONAL INFORMATION]

HIPAA WAIVER OF CONFIDENTIALITY FOR MY AGENT/REPRESENTATIVE

[INITIALS] – I intend for my agent to be treated as I would be with respect to my rights 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 1320d and 45 CFR160-164.

PART 3. LIVING WILL (End of Life Care)

1. My information (the “Principal”):

My Name: [PRINCIPAL’S NAME] My Age: [#]
My Address: [ADDRESS] Date of Birth: [DOB]
Telephone: [PHONE]

2. My decisions about end of life care:

[INITIALS] A. Comfort Care Only: If I have a terminal condition I do not want my life to be prolonged, and I do not want life- sustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death. (NOTE: “Comfort care” means treatment in an attempt to protect and enhance the quality of life without artificially prolonging life.)
[INITIALS] B. Specific Limitations on Medical Treatment I Want: (NOTE: Initial or mark one or more choices, talk to your doctor about your choices.) If I have a terminal condition, or am in an irreversible coma or a persistent vegetative state that my doctors reasonably believe to be irreversible or incurable, I do want the medical treatment necessary to provide care that would keep me comfortable, but I do not want the following:

[INITIALS] 1.) Cardiopulmonary resuscitation, for example, the use of drugs, electric shock, and artificial breathing.
[INITIALS] 2.) Artificially administered food and fluids.
[INITIALS] 3.) To be taken to a hospital if it is at all avoidable.

[INITIALS] C. Pregnancy: Regardless of any other directions I have given in this Living Will, if I am known to be pregnant I do not want life-sustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with the continued application of life-sustaining treatment.
[INITIALS] D. Treatment Until My Medical Condition is Reasonably Known: Regardless of the directions I have made in this Living Will, I do want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is terminal or is irreversible and incurable, or I am in a persistent vegetative state.
[INITIALS] E. Direction to Prolong My Life: I want my life to be prolonged to the greatest extent possible.

3. Other Statements or Wishes I Want Followed For End of Life Care:

☐ – A. I have not attached additional special provisions or limitations about End of Life Care I want.

☐ – B. I have attached additional special provisions or limitations about End of Life Care I want.

SIGNATURE VERIFICATION

A. I am signing this Living Will as follows:

Signature: _____________________________ Date: [DAY] day of [MONTH], 20[XX]

SIGNATURE OF WITNESS

A. Witness: I certify that I witnessed the signing of this document by the Principal. The person who signed this LivingWill appeared to be of sound mind and under no pressure to make specific choices or sign the document. I understand the requirements of being a witness. I confirm the following:

• I am not currently designated to make medical decisions for this person.
• I am not directly involved in administering health care to this person.
• I am not entitled to any portion of this person’s estate upon his or her death under a will or by operation of law.
• I am not related to this person by blood, marriage, or adoption.

Witness Name (printed): _____________________________

Signature: _____________________________ Date: [DAY] day of [MONTH], 20[XX]