Appointment of Health Care Agent 

This is who I want to make health care decisions for me if I am unable to make and communicate health care decisions for myself. 

When I am unable to make and communicate health care decisions 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] 

This is what I want my health care agent to be able to do if I am unable to make and communicate health care decisions for myself (I do understand I can change these choices): 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 make and communicate health care decisions 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 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 has 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]

My health care agent is not automatically given the powers listed below in (1) and (2). If I want my agent to have any of the powers in (1) and (2), I must initial the line in front of the power; then my agent will have that power.

[INITIALS] (1) To decide whether to donate any parts of my body, including organs, tissues, and eyes, when I die. 

[INITIALS] (2) To decide what will happen with my body when I  die (burial, cremation). 

Making the Document Legal

Prior designations revoked. I revoke any prior health care directive.

I sign my name to this Health Care Directive Form on [DAY] day of [MONTH], 20[XX] at [CITY] (city) [STATE] (state)

_____________________________________ (you sign here)

(This health care directive will not be valid unless it is notarized or signed by two qualified witnesses who are present when you sign or acknowledge your signature. If you have attached any additional pages to this form, you must date and sign each of the additional pages at the same time you date and sign this health care directive.)

Two Witnesses

Witness One:

1. In my presence on [DAY] day of [MONTH], 20[XX] (date), [NAME] (name of declarant) acknowledged the declarant’s signature on this document or acknowledged that the declarant directed the person signing this document to sign on the declarant’s behalf.
2. I am at least eighteen years of age.
3. If I am a health care provider or an employee of a health care provider giving direct care to the declarant, I must initial this box: [ ]. I certify that the information in (1) through (3) is true and correct.

_____________________________________
(Signature of Witness One)

[ADDRESS, CITY, STATE, ZIP CODE]

Witness Two:

1. In my presence on [DAY] day of [MONTH], 20[XX] (date), [NAME] (name of declarant) acknowledged the declarant’s signature on this document or acknowledged that the declarant directed the person signing this document to sign on the declarant’s behalf.
2. I am at least eighteen years of age.
3. If I am a health care provider or an employee of a health care provider giving direct care to the declarant, I must initial this box: [ ]. I certify that the information in (1) through (3) is true and correct.

_____________________________________
(Signature of Witness One)

[ADDRESS, CITY, STATE, ZIP CODE]