Source: https://www.findlegalforms.com/product/advance-health-directive/partner/angeline4160/
Timestamp: 2019-02-19 04:44:49
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Advanced Health Care Directive Form. Fast, easy and legally binding.
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Advance Health Care Directive FindLegalForms.com Sample Form
This Advance Health Care Directive is made up two documents, a Power of Attorney for Health Care and a Living Will. It is a wise choice for anyone to have these documents in place. If the unexpected happens, these documents will not only give you, but your loved ones peace of mind knowing that your wishes are being carried out. If you are already sick or disabled, these documents are all the more important, as they will not only give your loved ones guidance, but your physicians as well.
Information and Instructions for Advance Directive for Health Care (Power of Attorney for Health Care and Living Will);
Advance Directive for Health Care (Power of Attorney for Health Care and Living Will) Form.
Law Compliance: This form complies with the laws of your state.
You have the right to give instructions about your own health care. You also have the right to name someone else to make health-care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.
Part 1 of this form is a Power of Attorney for Health Care. Part 1 lets you name another individual as agent to make health-care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. (Your agent may not be an operator or employee of a community care facility or a residential care facility where you are receiving care, or your supervising health care provider or employee of the health care institution where you are receiving care, unless your agent is related to you or is a coworker. Additionally, you should consult an attorney before designating your conservator as your agent.)
(a) Consent or refuse to consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition.
(b) Select or discharge health-care providers and institutions.
(c) Approve or disapprove diagnostic tests, surgical procedures, and programs of medication.
(d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation.
Part 2 of this form lets you give specific instructions about any aspect of your health care, whether or not you appoint an agent. Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out Part 2 of this form.
Part 4 of this form lets you designate a physician to have primary responsibility for your health care. After completing this form, sign and date the form at the end. The form must be signed by two qualified witnesses or acknowledged before a notary public. Give a copy of the signed and completed form to your physician, to any other health-care provider you may have, to any health-care institution at which you are receiving care and to any health-care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.
PART 1 - POWER OF ATTORNEY FOR HEALTH CARE
Name of individual you choose as agent: ____________________________________
City, State, Zip Code: ___________________________________________________
Phone Home _____________________ Work: ______________________________
Name of individual you choose as alternate agent: ____________________________
Name of individual you choose as second alternate agent: ______________________
Phone Home _____________________ Work: _______________________________
(1.2) AGENT'S AUTHORITY: My agent is authorized to make all health care
decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:
(1.3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority ecomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box.
If I mark this box o my agent's authority to make health care decisions for me takes effect immediately.
be appointed for me by a court, I nominate the agent designated in this form. If that agent is not willing, able, or reasonably available to act as conservator, I nominate the alternate agents whom I have named, in the order designated.
PART 2 - INSTRUCTIONS FOR HEALTH CARE
o (a) Choice Not To Prolong Life
I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits,
o (b) Choice To Prolong Life
PART 3 - DONATION OF ORGANS AT DEATH - (OPTIONAL)
o (a) I give any needed organs, tissues, or parts, OR
o (b) I give the following organs, tissues, or parts only: _________________________
(c) My gift is for the following purposes (strike any of the
following you do not want):
PART 4 - PRIMARY PHYSICIAN - (OPTIONAL)
Name of physician: _____________________________________________________
Sign your name ______________________________________
Print your name ______________________________________
(5.3) STATEMENT OF WITNESSES: I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this advance health care directive is personally known to me, or that the individual's identity was proven to me by convincing evidence (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as
agent by this advance directive, and (5) that I am not the individual's health care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential
care facility for the elderly.
I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of
Signature of Witness: ___________________________________
PART 6 - SPECIAL WITNESS REQUIREMENT
Sign your name _____________________________________
Print your name: ___________________________________
Product number#16841
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I was very pleased with the 3 products I purchesed. The living Trust was a little confusing until I realized that filling out the questions did not enter the information in the final form and that these had to be reentered.
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