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LEGALDOCS - Durable Power of Attorney for Health Care Questionnaire


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This is an example of a completed Durable Power of Attorney for Health Care.


THERE IS A CHARGE OF $8.95 TO OBTAIN AND PRINT THIS DOCUMENT. You can proceed with the Questionnaire, and obtain a Durable Power of Attorney for Health Care free of charge, but to obtain the final, completed document, ready for viewing and instant printing (or Save-to-File), you will be asked to submit credit card information and will be billed $8.95. However, please feel free to complete or review this Questionnaire and the Summary which will be produced. It is educational and will provide some insight regarding which areas, minimally, should be covered, and will let you see if the subject matters important to you are covered in the Durable Power of Attorney for Health Care

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A power of attorney for health care decisions allows you to appoint another person to make health care decisions for you in the event you are mentally or physically unable to make health care decisions yourself. Unless you limit your agent's authority, your agent has authority to stop your doctor from giving you treatment, or stopping treatment to keep you alive. Chose a person you believe has the same or similar views as you do on health care treatment, and in continuing or discontinuing treatment if you have a terminal illness.


To complete your power of attorney for health care, fill out this form.

NAME AND RESIDENCE OF PRINCIPAL
The name of the person giving the Power of Attorney (the "Principal") is

The Principal resides in the

County of:
State of:

NAME OF POWER OF ATTORNEY
A Power of Attorney for Health Care decisions gives the Attorney-in-Fact authority to make health care decisions in the event you are unable to do so. This avoids the necessity of establishing a conservatorship of the person should you be unable to care for yourself or other incapacity. The Attorney-in-Fact for Health Care decisions can be, but is not necessarily the same person as the Attorney-in-Fact for financial matters. For example, you may trust your business partner with your financial matters, but that person may not share your beliefs regarding ending life sustaining equipment ("pulling the plug") or other matters.

I nominate as my Attorney in Fact for Health Care Decisions.

DESCRIPTION OF DESIRES REGARDING LIFE SUSTAINING TREATMENT
Choose one of the following:

I do not want my life to be prolonged and I do not want life-sustaining treatment to be provided or continued if the burdens of the treatment outweigh the expected benefits. I want my Agent to consider the relief of suffering and the quality as well as the extent of the possible extension of my life in making decisions concerning life-sustaining treatment.

I want my life to be prolonged and want life-sustaining treatment to be provided or continued, even though the burdens of the treatment outweigh the expected benefits. I want my Agent to consider the relief of suffering and the quality as well as the extent of the possible extension of my life in making decisions concerning life-sustaining treatment. ADDITIONAL DESCRIPTION OF DESIRES
If you want to add additional language to the above, finish this sentence.
IN ADDITION TO THE ABOVE, I WANT ....

.

INSPECTION AND DISCLOSURE OF MEDICAL RECORDS
Choose the powers your Agent has with dealing with your medical records. (As a default, all powers are chosen - click the ones you want to delete.)

To receive information regarding my physical and mental health, including access to my medical and hospital records.

To execute releases to obtain medical and hospital records and information.

To consent to the disclosure of this information.

POWER TO SIGN DOCUMENTS, WAIVERS AND RELEASES
Choose the powers your Agent has with dealing with waivers and releases. (As a default, all powers are chosen - click the ones you want to delete.)

To sign documents entitled "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advise" or similar.

To sign any necessary waiver or release from liability required by a hospital or physician.

AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS
Choose the powers your Agent has with dealing with these issues. (As a default, all powers are chosen - click the ones you want to delete.)

Authorize an autopsy.

Make a disposition of a part or parts of my body as an Anatomical Gift for use in another person.

Make a disposition of a part or parts of my body as an Anatomical Gift for educational or scientific purposes.

Direct the disposition of my remains (i.e., burial, cremation, or other).

DURATION
Specify the length of time this Power of Attorney shall remain in effect.

Unlimited Duration, until revoked by me at a later date.

This Power of Attorney expires on (For example, 8/19,2006)

ALTERNATE AGENTS
You are not required to chose an alternate agent. Any alternate agent you chose will be able to make the same health care decisions as your first chosen agent. If the agent or alternate agent is your spouse, he/she will not be entitled to act as your agent if your marriage is dissolved.

Leave the space blank if you do not want to chose an alternate agent.
In the event the first named person is unwilling or unable to act as Attorney in Fact for Health Care Decisions for any reason, I nominate as my Attorney in Fact for Health Care Decisions.




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