Who is this for? First Last This person is known as the "Patient" Mailing Address Patient's Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming 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 the decisions for themselves. Address of Health Care Agent Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming 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? Choose One (1)YesNo Name of Alternate Agent First Last Alternate Agent's Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming 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? Choose One (1)YesNo Name of 2nd Alternate Agent First Last 2nd Alternate Agent's Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code 2nd Alternate Agent's Phone Number Powers Would you like the Agent to have Access to your Medical Records? 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? Choose One (1)Yes, there will be LimitationsNo, there will not be Limitations 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? Choose One (1)Upon Mental DisabilityImmediately 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? Choose One (1)Patient's DeathSpecific 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? Choose One (1)YesNo In regards to Donating Organs, Authorizing an Autopsy, and the Direct Disposition of the Remains? Will there be any exceptions to this? Choose One (1)YesNo 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? Choose One (1)YesNo 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? Choose One (1)Yes, prolong my life as long as possibleNo, I would not want my life prolonged 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? Choose One (1)YesNo Are there any other wishes the Patient would like TO ADD in regards to their end-of-life treatment? Choose One (1)YesNo Add the following medical requests: Organ Donation Does the Patient wish to Donate any of their organs after their death? Choose One (1)YesNo Which parts of the body may be donated? Choose One (1)All Parts of the BodyOnly the Following: List the following body parts that may be used for organ donation: The Patient's organs may be used for: 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? Choose One (1)YesNo 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 Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Execution Under Michigan law, an Advance Directive is required to be signed with Two (2) Witnesses Under Michigan law, an Advance Directive is required to be signed with Two (2) Witnesses I Understand Next Save Save and finish later
