Advance Directive (Medical POA & Living Will)

Who is this for?

First

Last

This person is known as the "Patient"

The Patient is a resident of

Mailing Address

Patient's Address

Street Address

Address Line 2

City

State

ZIP Code

Health Care Agent

Who will be the Agent that can make MEDICAL DECISIONS for the Patient?

First

Last

The Agent can make medical decisions for the Patient ONLY IF the Patient cannot make decisions for themselves.

Address of Health Care Agent

Street Address

Address Line 2

City

State

ZIP Code

Agent's Contact Info

Agent's Cell Phone (Required)

Agent's Home Phone (if any)

Agent's Work Phone (if any)

Agent's E-Mail

1st Alternate Agent

Would the Patient like to have an Alternate Agent in the chance the Original cannot be reached?

Name of Alternate Agent

First

Last

Alternate Agent's Address

Street Address

Address Line 2

City

State

ZIP Code

Agent's Best Phone Number

2nd Alternate Agent

Would the Patient like to have a 2nd Alternate Agent in the chance the Original Agent and Alternate Agent cannot be reached?

Name of 2nd Alternate Agent

First

Last

2nd Alternate Agent's Address

Street Address

Address Line 2

City

State

ZIP Code

2nd Alternate Agent's Phone Number

Powers

Would you like the Agent to have Access to your Medical Records?

YesNo

In accordance with HIPAA (Health Insurance Portability and Accountability Act) of 1996, 42 USC 1320d, 45 CFR 160-164.

Will there be ANY limitation to the Agent's Powers?

If "No", then the Agent may have the power to choose to withdraw artificial life-sustaining breathing, drinking, and/or feeding.

The 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 for survival, except as I state here:

Start & End Date

Is the Agent able to start Immediately or Upon Mental Disability?

Most documents are set to allow the Agent to begin making Medical Decisions "Upon Mental Disability".

Will this Medical Power of Attorney end upon the Patient's Death or on a Specific Date?

This document most commonly ends upon the patient's death.

Enter the End Date of this Medical Power of Attorney

Powers After Death

Will the Agent have powers after the Patient's death?

In regards to Donating Organs, Authorizing an Autopsy, and the Direct Disposition of the Remains?

Will there be any exceptions to this?

Exceptions to Post-Death Powers of the Agent

Living Will

Would the Patient like to have a Living Will added to their Medical Power of Attorney?

If yes, this form will specifically state what the Patient would like to receive for End-of-Life treatment to hospital staff in the chance their Agent is not available.

Would the Patient like to prolong their life EVEN IF they are determined to be in an irreversible condition or permanently unconscious?

If medical staff believe that the patient is in pain, would the patient like to elect TO HAVE pain medication be given even if it risks death?

Are there any other wishes the Patient would like TO ADD in regards to their end-of-life treatment?

Add the following medical requests:

Organ Donation

Does the Patient wish to Donate any of their organs after their death?

Which parts of the body may be donated?

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

The Patient's organs may be used for:

TransplantTherapyResearchEducation

Power of Attorney Location

Copies of this Medical Power of Attorney shall be kept at the following location(s):

Such as a Doctor's Office, Attorney, Family Member(s), Friend(s), etc.

Primary Care Physician

Does the Patient want to enter their Primary Care Physician's information?

What is the Name of the Primary Care Physician?

First

Last

Primary Physician's Phone Number

Primary Care Physician's Office Address

Street Address

Address Line 2

City

State

ZIP Code

Execution

Under State law, the Patient is required to sign this document in the presence of Two (2) Witnesses.

I Understand

The two (2) witnesses cannot be related by blood, benefit from the patient's estate, or be medical staff.

Under Arizona law, the Patient is required to sign in the presence of One (1) Witness or a Notary Public.

I Understand

A Notary Public is recommended.

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 (1) 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 (2) Witnesses or a Notary Public.

I Understand

If the Patient decided to sign with Two (2) 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 either Two (2) Witnesses AND a Notary Public.

I Understand

Under State law, the Patient is only required to sign but is recommended to be signed with a Notary Public.

I Understand

If notarized, no 3rd party will be able to claim the Patient did not sign out of their own free will. A notarization legitimizes any document as being signed by the actual signer.