Who is this Medical Power of Attorney for? Who is this Medical Power of Attorney for? MyselfMy childMy spouse or partnerMy parent or relativeSomeone else What is the patient's name? This individual will be known as the "patient" on this document. If you are the patient, enter your name. What is the patient's mailing address? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Who will be making medical decisions for the patient? This individual will be known as the "surrogate" on this document. Relationship to patient What is the surrogate's mailing address? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Surrogate's phone number Surrogate's email address Does the patient want to appoint an alternate surrogate? Does the patient want to appoint an alternate surrogate? YesNo In case the primary surrogate is unavailable or unwilling to make a decision on the patient's 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 Does the patient want to appoint a second alternate surrogate? Does the patient 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 the patient? Will the surrogate have the authority to make all healthcare decisions for the patient? 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 the patient, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care for survival, except as stated here: Will the surrogate be granted access to the patient's medical records? Will the surrogate be granted access to the patient's 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 the patient's incapacitationImmediately Will the surrogate have certain authorities after the patient's death? Will the surrogate have certain authorities after the patient's 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: Does the patient wish to add any specific instructions not yet mentioned? Does the patient wish to add any specific instructions not yet mentioned? YesNo Enter the instructions here: Does the patient want to add a living will to this document? Does the patient want to add a living will to this document? YesNo A living will outlines the patient's preferences for end-of-life treatment for hospital staff in case the surrogate is unavailable. The patient's life should NOT be artificially prolonged if the patient is: (select all that apply) The patient's life should NOT be artificially prolonged if the patient is: (select all that apply) Incapacitated and have a terminal conditionIncapacitated and have an end-stage conditionIncapacitated and in a persistent vegetative stateNone of the above The patient does NOT want to receive: (select all that apply) The patient does NOT want to receive: (select all that apply) Cardiac resuscitationMechanical respirationArtificial nutrition or hydrationAntibioticsNone of the above Does the patient want maximum pain relief even if it hastens their death? Does the patient want maximum pain relief even if it hastens their death? YesNo Does the patient wish to include any other medical requests? Does the patient wish to include any other medical requests? YesNo Add the following medical requests: Does the patient wish to donate any organs after their death? Does the patient wish to donate any organs after their 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: The patient's organs may be used for: The patient's organs may be used for: TransplantTherapyResearchEducation Does the patient want to add their primary care physician's information? Does the patient want to add their 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? 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
