I am creating this for I am creating this for MyselfSomeone else Who is this for? Who will be appointed as your health care surrogate? Relationship Do you want to enter your surrogate's contact information? Do you want to enter your surrogate's contact information? YesNo, I will enter it later. Phone number Email address Mailing address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Do you want to appoint an alternate surrogate? Do you want to appoint an alternate surrogate? YesNo In case the primary surrogate is unavailable or unwilling to make a decision on your behalf. Name of alternate surrogate Phone number Mailing address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Do you want to appoint a second alternate surrogate? Do you want to appoint a second alternate surrogate? YesNo In case both the primary surrogate and 1st alternate surrogate are unavailable or unwilling. Name of second alternate surrogate Phone number Mailing address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Will the surrogate have the authority to make all healthcare decisions for you? Will the surrogate have the authority to make all healthcare decisions for you? YesNo, there will be limitations. Without any limitations, the surrogate may have the power to withdraw life-sustaining care, drinking, and/or feeding. The surrogate is authorized to make all healthcare decisions for me, except as stated here: Will the surrogate be granted access to your medical records? Will the surrogate be granted access to your medical records? YesNo In accordance with HIPAA (Health Insurance Portability and Accountability Act) of 1996 When will the surrogate's powers become effective? When will the surrogate's powers become effective? Upon my mental incapacitationImmediately Will the surrogate have certain authorities after your death? Will the surrogate have certain authorities after your death? YesNo Related to donating organs, authorizing an autopsy, disposing the body, etc. Will there be exceptions to this? Will there be exceptions to this? YesNo List the exceptions: Do you wish to add any specific instructions not yet mentioned? Do you wish to add any specific instructions not yet mentioned? YesNo Enter the instructions here: Do you want to add a living will to this document? Do you want to add a living will to this document? YesNo A living will outlines your preferences for end-of-life treatment for hospital staff in case the surrogate is unavailable. My life should NOT be artificially prolonged if I am: (select all that apply) My life should NOT be artificially prolonged if I am: (select all that apply) Incapacitated and have a terminal conditionIncapacitated and have an end-stage conditionIncapacitated and in a persistent vegetative stateMy life should always be prolonged I do NOT want to receive the following life-sustaining treatments: (select all that apply) I do NOT want to receive the following life-sustaining treatments: (select all that apply) Cardiac resuscitationMechanical respirationArtificial nutrition or hydrationAntibioticsI want to receive all treatments Do you want maximum pain relief even if it hastens your death? Do you want maximum pain relief even if it hastens your death? YesNo Do you wish to include any other medical requests? Do you wish to include any other medical requests? YesNo Add the following medical requests: Do you wish to donate any organs after your death? Do you wish to donate any organs after your death? YesNo Which parts of the body? Which parts of the body? All parts of the bodyOnly the following: List the body parts that may be used for organ donation: My organs may be used for: My organs may be used for: TransplantTherapyResearchEducation Do you want to add your primary care physician's information? Do you want to add your primary care physician's information? YesNo Physician's name Phone number Office address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Where will copies of this document be held? Do you want to add your mailing address? (optional) Do you want to add your mailing address? (optional) YesNo Mailing address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code The principal must sign this document in the presence of at least two witnesses. The principal must sign this document in the presence of at least two witnesses. I understand. Next Save Save and finish later
