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Rhode Island Advance Directive (Health Care) Power of Attorney Form

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Rhode Island Advance Directive (Health Care) Power of Attorney Form is used when you are seeking to have a loved one be in charge of your health care when you are beyond the point of being able to communicate your wishes to your medical providers. You will want to choose someone who understands your wishes and who is willing to act in your best interests. It is comforting to know that someone you love is taking care of your needs when not being able to speak for yourself. This form is in two (2) parts, the first is where you appoint your agent and the second part is where you explain your wishes to your agent.

Laws – Chapter 23-4.10 (Health Care Power of Attorney)

Living Will – Make specific instructions made out to medical staff as your final wishes if you are not in a position to make them yourself.

Durable Power of Attorney – A durable power of attorney, in the case of this document, will enable you to transfer the responsibility of managing your financial affairs to a trusted legal representative.

How to Write

1 – Obtain A Blank Copy Of The Directive Template Form

To obtain the document with the structure and wording required to name a Health Care Agent, you will need to obtain a workable copy of the template form on this page. It is accessible in one of three formats: PDF, ODT, and MS Word. Select the version appropriate for your system or open the PDF version and print it. It is strongly recommended to save a copy regardless of whether you are working with a live on-screen document or a paper copy. Before filling this out or obtaining the Principal’s information, make sure the Principal reads the initial instruction pages. The Principal should be made very well-acquainted with this document before supplying it with the information it requests.

2 – Formally Designate The Health Care Agent As The Recipient Of Principal Authority

The first part of this template “Designation Of Health Care Agent” presents a well-defined area so the Principal can officially present his or her intention of naming the Health Care Agent with the Principal Authority to handle his or her Medical Decisions if the Principal becomes incapacitated. This process will begin by supplying the Full Name, Address, and Contact Telephone Number on the first three blank lines. The next three blank lines (labeled “Name Of Agent,” “Address Of Agent,” and “Phone Number(s) Of Agent”) should have the Identity, the Physical Location, and the Contact Telephone Number of the Agent provided.

3 – The Principal Must Review Health Care Decisions The Attorney-in-Fact Can Effect

The next couple of sections should be read by the Principal to comprehension. The first area requiring attention is part 4, bearing the Title “Statement Of Desires, Special Provisions, And Limitations,” here some fairly specific directives will be preset into this document by default however, the Principal will have the ultimate say on what should be included in this paperwork as obligatory instructions the Health Care Agent must follow. The first task will be to review the list of Principal Directives in the section “(a) Statement Of Desires Concerning Life-Prolonging Care, Treatment, Services, And Procedures.”  The Principal does have the option to remove most of these items upon the advice of an attorney or physician if such action will not break any local or state statutes.

4 – Any Principal Adjustments Or Instructions Concerning Principal Power Must Be Declared

Locate the subtitle “When My Death Is Imminent.” Item 1 of this section will present the scenario of the Principal having no more than one week of life remaining regardless of any Medical Care or Intervention provided. The Principal can specify precisely what he or she wants and does not want. For instance, the Principal may wish to have any artificial nutrition or artificial hydration withheld but still to receive medication when necessary. Such a desire should be reported on the blank lines provided in this item. The Principal should be very specific especially if he or she wishes to impose such restrictions on treatment depending on the nature of the Medical Event or on the state he or she is in. For instance, the Principal may be in a medically induced coma and may wish to be allowed consciousness during this last week but only if he or she is not in pain. This is an example of a very specific request and any such request or preference that is legal that the Principal wishes for regarding the Health Care options available should be painstakingly clear.In the second item, the Principal can address the possibility of being diagnosed with a terminal condition where he or she will not live more than three months. The Principal should state any preferences he or she has for any scenario that is of concern. He or she can provide a directive of preferred treatments or forbid certain types of medical care. For example, the Principal may have very serious religious or spiritual concerns that will affect what he or she will allow. As with the previous item, the Principal should be as specific as possible.The third item will supply an area where the Principal can place any conditions, limitations, and/or instructions regarding Medical Health Care Decisions the Principal expects Health Care Agent to make on his or her behalf in any situation the Principal can imagine. Any directives supplied on the blank lines in this section must remain within the confines of Rhode Island State and Federal Laws.The fourth item here will deal with Pregnancies. If the Principal agrees with the statements made in this item, she should sign the blank line labeled “Signature Of Declarant”If the Principal has any additional Instructions, Preferences, Provisions, Restrictions, or Extensions of Power that should apply to this document, these directives may be included as a well-labeled, signed attachments as per item (b)

The Principal may also make organ or tissue donations under the Uniform Pursuant Gift Act. If he or she wishes the Health Care Agent to inform his or her family and friends of this intention, then the Principal must initial the blank space and mark the brackets associated with the statement beginning with “In The Event Of My Death” in item “(c) Statement Of Desire Regarding Organ And Tissue Donation.”

5 – Report Any Termination Date That Should Apply To These Powers Before The Signing

This document’s grant of Power to the Agent will remain in effect until the Principal passes away. This can be changed in Part 7. If the Principal wishes the Principal Powers delivered to the Health Care Agent to automatically terminate then record the Termination Date on the blank line furnished under the title “Duration.” If this line is left blank the Health Care Agent will retain Principal Power until the Principal dies or issues a revocation

6 – Alternate Agents Can Be Set In Place As A Precaution

The Health Care Agent named in Part 1 has quite a responsibility to the Principal. However, disastrous effects can result if the Health Care Agent is unable, unavailable, or ineligible to carry out the Principal’s Directives as presented in this document. To ensure the Principal’s Directives are carried out, he or she may determine that an Alternate Agent should succeed the Health Care Agent in possessing Principal Power. Any such Agent must be named here if this is the case. The eighth part of this Directive will allow the Principal to name such Agents. There will be enough room to name two Alternate Agents who will assume Principal Power in the order they are listed. Record the Name, Address, and Phone Number of the First Alternate Agent who will assume Principal Power (if necessary) in the item labeled “A. First Alternate Agent” and the second Alternate Agent’s Name, Address, and Telephone Number in the item labeled “B. Second Alternate Agent.”

7 – The Principal’s Witnessed Signature Is Mandatory

The Principal must sign his or her Name to these Directives in order to officially issue them. To begin this process, he or she should find the section labeled “Date And Signature Of Principal” then, record the Signature Date on the blank line labeled “Date” then fill in the City and State where this document was signed on the next blank line.Finally, the Principal should sign his or her Name on the “Signature” line.Next, the two individuals acting as a Witness to the Principal Signing must provide a testimonial Signature. It should be noted that neither Witness may be a Health Care Provider, Health Care Provider Employee, Communicate Care Facility Operator, Community Care Facility Employee, or any of the Agents named above. Each Witness must read the statement beginning with “I Declare Under Penalty Of Perjury That The Person Who Signed…” then sign his or her Name, document his or her Residential Address, Print his or her Name, and record the current Date on the blank lines provided below this statement.If this document will be notarized, it will need to be done in the section beginning with the words “Notary Public Signature.” This is not necessarily required for the execution of this paperwork however, it is considered very wise.At least one Witness who is not related to the Principal by “Blood, Marriage, or Adoption” and not entitled to any part of the Principal’s Estate upon the death of the Principal must locate the statement “I Further Declare Under Penalty” then sign and print his or her name to attest to this status.


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