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Ohio Advance Directive Form

An Ohio advance directive is a form used to authorize someone else to make any and all healthcare decisions for the principal who signs it. The agent will have the authority to consent to the administration of pain-relieving drugs or life-sustaining procedures, among other healthcare treatments. The form also authorizes the agent to make decisions about where the principal is treated.

Signing Requirements (§ 2133.02(A)(1), § 1337.12(B)(C)) – Two (2) witnesses or a notary public.

Statutory Form

Ohio Advance Directive for Healthcare

Naming of My Agent. The person named below is my agent, who will make health care decisions for me as authorized in this document.

Agent’s name and relationship: [NAME and RELATIONSHIP]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Telephone number(s): [PHONE NUMBER]

By placing my initials, signature, check or other mark in this box, I specifically authorize my agent to obtain my protected health care information immediately and at any future time.

Guidance to Agent. My agent will make health care decisions for me based on my instructions in this document and my wishes otherwise known to my agent. If my agent believes that my wishes conflict with what is in this document, this document will take precedence. If there are no instructions and if my wishes are unclear or unknown for any particular situation, my agent will determine my best interests after considering the benefits, the burdens and the risks that might result from a given decision. If no agent is available, this document will guide decisions about my health care.

Naming of alternate agent(s). If my agent named above is not immediately available or is unwilling or unable to make decisions for me, then I name, in the following order of priority, the persons listed below as my alternate agents:

Alternate agent’s name and relationship: [NAME and RELATIONSHIP]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Telephone number(s): [PHONE NUMBER]

Any person can rely on a statement by any alternate agent named above that he or she is properly acting under this document and such person does not have to make any further investigation or inquiry

Authority of Agent. Except for those items I have crossed out and subject to any choices I have made in this Health Care Power of Attorney, my agent has full and complete authority to make all health care decisions for me. This authority includes, but is not limited to, the following:

  1. To consent to the administration of pain-relieving drugs or treatment or procedures (including surgery) that my agent, upon medical advice, believes may provide comfort to me, even though such drugs, treatment or procedures may hasten my death.
  2. If I am in a terminal condition and I do not have a Living Will Declaration that addresses treatment for such condition, to make decisions regarding life-sustaining treatment, including artificially or technologically supplied nutrition or hydration.
  3. To give, withdraw or refuse to give informed consent to any health care procedure, treatment, interventions or other measure.
  4. To request, review and receive any information, verbal or written, regarding my physical or mental condition, including, but not limited to, all my medical and health care records.
  5. To consent to further disclosure of information and to disclose medical and related information concerning my condition and treatment to other persons.
  6. To execute for me any releases or other documents that may be required in order to obtain medical and related information.
  7. To execute consents, waivers and releases of liability for me and for my estate to all persons who comply with my agent’s instructions and decisions. To indemnify and hold harmless, at my expense, any person who acts while relying on this Health Care Power of Attorney. I will be bound by such indemnity entered into by my agent.
  8. To select, employ and discharge health care personnel and services providing home health care and the like.
  9. To select, contract for my admission to, transfer me to or authorize my discharge from any medical or health care facility, including, but not limited to, hospitals, nursing homes, assisted living facilities, hospices, adult homes and the like.
  10. To transport me or arrange for my transportation to a place where this Health Care Power of Attorney is honored, if I am in a place where the terms of this document are not enforced.
  11. To complete and sign for me the following:
    1. Consents to health care treatment, or to the issuing of Do Not Resuscitate (DNR) Orders or other similar orders; and
    2. Requests to be transferred to another facility, to be discharged against health care advice, or other similar requests; and
    3. Any other document desirable or necessary to implement health care decisions that my agent is authorized to make pursuant to this document

SIGNATURE of PRINCIPAL

I understand that I am responsible for telling members of my family and my physician, my lawyer, my religious advisor and others about this Health Care Power of Attorney. I understand I may give copies of this Health Care Power of Attorney to any person. I understand that I may file a copy of this Health Care Power of Attorney with the probate court for safekeeping. I understand that I must sign this Health Care Power of Attorney and state the date of my signing, and that my signing either must be witnessed by two adults who are eligible to witness my signing OR the signing must be acknowledged before a notary public.

I sign my name to this Health Care Power of Attorney:
_____________________________________________

Witness Signature:
_____________________________________________

Witness Signature:
_____________________________________________