Advance Directive (Medical Power of Attorney & Living Will)

Who is this for?

Who will be appointed as your healthcare agent?

Do you want to enter the agent's contact info now?

YesNo, I will enter it later.

Phone number

Email address

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

Do you want to appoint an alternate agent?

YesNo

In case the original agent is unavailable or unwilling to make a decision on the patient's behalf.

Name of alternate agent

Phone number

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

Do you want to appoint a second alternate agent?

YesNo

In case both the original agent and the first alternate agent are unavailable or unwilling to make a decision on the patient's behalf.

Name of second alternate agent

Phone number

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

Will the agent be granted access to your medical records?

YesNo

In accordance with HIPAA (Health Insurance Portability and Accountability Act) of 1996.

Will there be any limitations to the agent's powers?

Yes, there will be limitations.No, there will not be any limitations.

Without any limitations, the agent may have the power to choose to withdraw life-sustaining care, drinking, and/or feeding.

The agent is authorized to make all healthcare decisions for me, except as I state here:

When will the agent's powers become effective?

Upon my incapacitationImmediately

Typically, the agent is granted power upon the principal's incapacitation.

When will the agent's powers be terminated?

Upon my deathOn a specified end date

Most commonly, the agent's powers are terminated upon the principal's death.

Enter the end date:

Will the agent have certain authorities after your death?

YesNo

Related to donating organs, authorizing an autopsy, and the direct disposition of the remains.

Will there be any exceptions to this?

YesNo

List the exceptions:

Do you want to add a Living Will to this Medical Power of Attorney?

YesNo

A Living Will specifically states the principal's preferences for end-of-life treatment for hospital staff in case their agent is not available.

Do you want to prolong your life even if you are determined to be in an irreversible condition or permanently unconscious?

Yes, I want to prolong my life as long as possible.No, I do not want my life prolonged.

If medical staff believe that you are in pain, do you want to be given pain medication even if it hastens death?

YesNo

Are there any other wishes you want to add to your end-of-life treatment?

YesNo

Add the following medical requests:

Do you wish to donate any of your organs after your death?

YesNo

Which parts of the body may be donated?

All parts of the bodyOnly specified organs

List the following body parts that may be used for organ donation:

My organs may be used for:

TransplantTherapyResearchEducation

Do you want to enter your primary care physician's information?

YesNo

Physician's name

Phone number

Office address

Street Address

Address Line 2

City

State

ZIP Code

Where will copies of this medical power of attorney will be held?

Do you want to enter your mailing address?

YesNo

This information may be required depending on the state you reside in.

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

I am a resident of

Under state law, the patient is required to sign this document in the presence of two witnesses.

I understand.

The two witnesses cannot be related by blood, be a beneficiary of the patient's estate, or be medical staff.

Under Arizona law, the patient is required to sign in the presence of one witness or a notary public.

I understand.

If the patient decides to sign in front of a witness, the witness cannot be blood-related, medical staff, or a beneficiary in the patient's will.

Under Utah law, the patient is required to sign in the presence of one witness.

I understand.

The witness can be a notary public but cannot be a person who is blood-related, a beneficiary in the patient's will, or medical staff.

Under state law, the patient is required to sign with either two witnesses or a notary public.

I understand.

If the patient decides to sign with two witnesses, they cannot be blood-related, a beneficiary in the patient's will, or medical staff.

Under state law, the patient is required to sign with two witnesses and a notary public.

I understand.

Under state law, the patient is only required to sign. However, it is recommended to sign in the presence of a notary public.

I understand.

If the document is notarized, no third party will be able to claim that the patient did not sign out of their own free will. A notarization legitimizes any document as being signed by the actual signer.

Do you wish to have this document notarized?

YesNo

Under Virginia law, medical powers of attorney require only two witnesses. However, a notary certificate may be added for extra protection.

Additionally, a notary acknowledgment is required if the medical power of attorney grants powers to the agent to make funeral arrangements and dispose of the declarant's remains.

Indiana Advance Directive (Medical Power of Attorney & Living Will)