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Washington D.C. Advance Directive Form

A Washington D.C. advance directive is a document that allows someone to appoint someone else to make healthcare decisions for them. This becomes useful in case the principal becomes unable to make decisions for themselves due to mental incompetence. The directive also allows the principal to state any type of treatment that they do not desire.

Signing Requirements (§ 7-622(a)(4) and § 21–2205(c)) – Two (2) witnesses.

Statutory Form

POWER OF ATTORNEY FOR HEALTH CARE

“I, [NAME], hereby appoint:

[NAME]

[PHONE NUMBER]
home telephone number

[PHONE NUMBER]
work telephone number

as my attorney in fact to make health-care decisions for me if I become unable to make my own health-care decisions. This gives my attorney in fact the power to grant, refuse, or withdraw consent on my behalf for any health-care service, treatment or procedure. My attorney in fact also has the authority to talk to health-care personnel, get information and sign forms necessary to carry out these decisions.

“With this document, I intend to create a power of attorney for health care, which shall take effect if I become incapable of making my own health-care decisions and shall continue during that incapacity.

“My attorney in fact shall make health-care decisions as I direct below or as I make known to my attorney in fact in some other way.

“(a) STATEMENT OF DIRECTIVES CONCERNING LIFE-PROLONGING CARE, TREATMENT, SERVICES, AND PROCEDURES:
“(b) SPECIAL PROVISIONS AND LIMITATIONS:

“BY MY SIGNATURE I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT.

“I sign my name to this form on [DAY] day of [MONTH], 20[XX] at [ADDRESS, CITY, STATE, ZIP CODE].

_______________________________________________
(Signature)

WITNESSES

“I declare that the person who signed or acknowledged this document is personally known to me, that the person signed or acknowledged this durable power of attorney for health care in my presence, and that the person appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as the attorney in fact by this document, nor am I the health-care provider of the principal or an employee of the health-care provider of the principal.

Signature: ________________________________________
Home Address: [ADDRESS, CITY, STATE, ZIP CODE]
Print Name: _______________________________________
Date: [DAY] day of [MONTH], 20[XX]

Signature: ________________________________________
Home Address: [ADDRESS, CITY, STATE, ZIP CODE]
Print Name: _______________________________________
Date: [DAY] day of [MONTH], 20[XX]

(AT LEAST 1 OF THE WITNESSES LISTED ABOVE SHALL ALSO SIGN THE FOLLOWING DECLARATION.)

“I further declare that I am not related to the principal by blood, marriage or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal under a currently existing will or by operation of law.

Signature: ________________________________________