HEALTH CARE DIRECTIVE

I, [NAME], understand this document allows me to do ONE OR BOTH of the following:

PART I: Name another person (called the health care agent) to make health care decisions for me if I am unable to decide or speak for myself. My health care agent must make health care decisions for me based on the instructions I provide in this document (Part II), if any, the wishes I have made known to him or her, or must act in my best interest if I have not made my health care wishes known.

AND/OR

PART II: Give health care instructions to guide others making health care decisions for me. If I have named a health care agent, these instructions are to be used by the agent. These instructions may also be used by my health care providers, others assisting with my health care and my family, in the event I cannot make decisions for myself.

APPOINTMENT OF HEALTH CARE AGENT

When I am unable to decide or speak for myself, I trust and appoint [NAME] to make health care decisions for me. This person is called my health care agent.

Relationship of my health care agent to me: [RELATIONSHIP]
Telephone number of my health care agent: [PHONE NUMBER]
Address of my health care agent: [ADDRESS, CITY, STATE, ZIP CODE]

My health care agent is automatically given the powers listed below in (A) through (D). My health care agent must follow my health care instructions in this document or any other instructions I have given to my agent. If I have not given health care instructions, then my agent must act in my best interest.

Whenever I am unable to decide or speak for myself, my health care agent has the power to:

(A) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care, treatment, service, or procedures. This includes deciding whether to stop or not start health care that is keeping me or might keep me alive, and deciding about intrusive mental health treatment.
(B) Choose my health care providers.
(C) Choose where I live and receive care and support when those choices relate to my health care needs.
(D) Review my medical records and have the same rights that I would have to give my medical records to other people.

If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR if I want to LIMIT any power in (A) through (D), I MUST say that here:

[LIMITATIONS]

MAKING THE DOCUMENT LEGAL

This document must be signed by me. It also must either be verified by a notary public (Option 1) OR witnessed by two witnesses (Option 2). It must be dated when it is verified or witnessed.

I am thinking clearly, I agree with everything that is written in this document, and I have made this document willingly.

My Signature: ___________________________________

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

Two Witnesses

Two witnesses must sign. Only one of the two witnesses can be a health care provider or an employee of a health care provider giving direct care to me on the day I sign this document.

Witness One:

1. In my presence on [DAY] day of [MONTH], 20[XX], [NAME] (name) acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf.
2. I am at least 18 years of age.
3. I am not named as a health care agent or an alternate health care agent in this document.
4. If I am a health care provider or an employee of a health care provider giving direct care to the person listed above in (A), I must initial this box: [INITIALS]

I certify that the information in (i) through (iv) is true and correct.

Signature: ______________________________________

Witness Two:

1. In my presence on [DAY] day of [MONTH], 20[XX], [NAME] (name) acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf.
2. I am at least 18 years of age.
3. I am not named as a health care agent or an alternate health care agent in this document.
4. If I am a health care provider or an employee of a health care provider giving direct care to the person listed above in (A), I must initial this box: [INITIALS]

I certify that the information in (i) through (iv) is true and correct.

Signature: ______________________________________