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Sample health care durable power of attorney
Any legal document should be prepared and reviewed by an attorney whenever possible. In real life that doesn't always happen. This sample language of a health care advocate form is provided for such occasions when attorney preparation is not possible.
The usual disclaimers apply as you might expect. This is not legal advice; I am not an attorney; no representation is made as to suitability of this language. This document is not intended to replace the need for a will, living will, durable power of attorney other estate planning documents. The language is also available in a downloadable Word document format. The language on the downloaded form may be slightly different than the Web page.
Durable power of attorney
TO MY FAMILY,
DOCTORS AND ALL CONCERNED WITH MY CARE:
These instructions
express my wishes about my health care. I want my family, doctors,
and everyone else concerned with my care to act in accord with them.
1. Appointment
of Patient Advocate
I appoint the following person my Patient
Advocate:
Patient Advocate’s Name:
Address:
2. Appointment
of Successor Patient Advocate
I appoint the following person my
successor Patient Advocate if my Patient Advocate does not accept my
appointment, is incapacitated, resigns or is removed. My successor
Patient Advocate is to have the same powers and rights as my Patient
Advocate.
Name:
[Successor]
Address:
My Patient
Advocate may delegate her powers to the successor Patient Advocate
if she is unable to act.
My Patient Advocate or successor Patient Advocate may
only act if I am unable to participate in making decisions regarding
my medical treatment.
3. Instructions
for Care
My Patient Advocate shall have the authority to make all
decisions and to take all actions regarding my care, custody and
medical treatment, including, but not limited to the following:
a. Have access to, obtain copies of and authorize release of my
medical and other personal information.
b. Employ and discharge
physicians, nurses, therapists, and any other health care providers,
and arrange to pay them reasonable compensation.
c. Consent to,
refuse or withdraw for me any medical care; diagnostic, surgical, or
therapeutic procedure; or other treatment of any type or nature,
including life sustaining treatments. I understand that life
sustaining treatment includes, but is not limited to breathing with
the use of a machine and receiving food, water and other liquids
through tubes. I also understand that these decisions could or would
allow me to die. I have listed below any specific instructions I
have related to life-sustaining treatments.
My Patient
Advocate is to be guided in making medical decisions for me by what
I have told him/her about my personal preferences regarding my care.
I understand that this decision could or would allow me to die.
4. Effect
This document
is to be treated as a Durable Power of Attorney for Health Care and
shall survive my disability or incapacity.
5. HIPAA
Release Authority
This instrument is meant to be an unlimited,
full and complete authorization for the release of any and all
protected medical information as defined under the Health Insurance
Portability and Accountability Act of 1996 (“HIPAA”), 42 USC 1320d
and 45 CFR 160-164, as amended, and under the rules and regulations
thereunder, and covers all protected information.
It is
understood that my Patient Advocate to whom this authorization is
given has my permission
to use and disseminate this information
in my Patient Advocate’s sole discretion.
a. I intend for my
Patient Advocate to be treated as I would be with respect to my
rights regarding the use and disclosure of my individually
identifiable health
information or other medical records. This
release authority applies to any information governed by HIPAA.
b. I authorize any physician, health care professional, dentist,
health plan, hospital, clinic, laboratory, pharmacy or other covered
health care provider, any insurance company and the Medical
Information Bureau, Inc. or other health care clearinghouse that has
provided treatment or services to me or that has paid for or is
seeking payment from me for such services to give, disclose and
release to my Patient Advocate, without restriction, all my
individually identifiable health information and medical records,
including all information relating to the diagnosis
and treatment
of HIV/AIDS, sexually transmitted diseases, mental illness and drug
or alcohol abuse.
c. The authority given my Patient Advocate
shall supersede any prior agreement that I may have made with my
health care providers to restrict access to or disclosure of my
individually identifiable health information.
d. The authority
given my Patient Advocate has no expiration date and shall expire
only in the event that I revoke the authority in writing and deliver
it to my health care provider.
6. Miscellaneous Provisions
If
I am unable to participate in making decisions for my care and there
is no Patient Advocate or successor Patient Advocate able to act for
me, I request that the instructions I have given in this document be
followed and that this document be treated as conclusive evidence of
my wishes.
It is also my intent that anyone participating in my
medical treatment shall not be liable for following the directions
of my Patient Advocate that are consistent with my instructions.
This
document is signed in the State of ___________. It is my intent that
the laws of the State of _________ govern all questions concerning
its validity, the interpretation of its provisions and its
enforceability. I also intend that it be applied to the fullest
extent possible wherever I may be.
I hereby
revoke any and all prior Health Care Powers of Attorney executed by
me.
Photocopies of
this document can be relied upon as though they were originals.
I am providing
these instructions of my free will. I have not been required to give
them in order to receive or have care withheld or withdrawn.
I am at least
eighteen (18) years old and of sound mind.
Date:
____________________________________
Name:
Address:
Witness
Statement and Signature
I declare that the person who signed this
Designation of Patient Advocate signed it in my presence and is
known to me. I also declare that the person who signed appears to be
of sound and under no duress, fraud, or undue influence and is
not my husband or wife, parent, child, grandparent, brother or
sister. I declare that I am not the presumptive heir of the person
who signed this document, the known beneficiary of her will at the
time of witnessing, her
physician or a person named as the
Patient Advocate. I also declare that I am not an employee of a life
or health insurance provider for the person who signed, an employee
of a health facility that is treating her, or an employee of a home
for the aged where she resides and that I am at least eighteen (18)
years old.
WITNESSES:
Address:
ACCEPTANCE OF
PATIENT ADVOCATE
I agree to be the Patient Advocate for
____________________ (called “Patient” in the rest of this
document). I accept the Patient’s designation of me as Patient
Advocate. I understand and
agree to take reasonable steps to
follow the desires and instructions of the Patient as indicated in
the Designation of Patient Advocate, in other written instructions
of the Patient and as we have
discussed verbally.
I also
understand and agree that:
a. This designation shall not become
effective unless the Patient is unable to participate in medical
treatment decisions.
b. A Patient Advocate shall not exercise
powers concerning the Patient’s care, custody, and medical treatment
that the Patient, if the Patient were able to participate in the
decision, could not have exercised on his or her own behalf.
c.
This designation cannot be used to make a medical treatment decision
to withhold or withdraw treatment from a Patient who is pregnant
that would result in the pregnant Patient’s death.
d. A Patient
Advocate may make a decision to withhold or withdraw treatment which
would allow a Patient to die only if the Patient has expressed in a
clear and convincing manner that the Patient Advocate is authorized
to make such a decision, and that the Patient acknowledges that such
a decision could or would allow the Patient’s death.
e. A Patient
Advocate shall not receive compensation for the performance of his
or her authority, rights, and responsibilities, but a Patient
Advocate may be
reimbursed for actual and necessary expenses
incurred in the performance of his or her authority, rights and
responsibilities.
f. A Patient Advocate shall act in accordance
with the standards of care applicable to fiduciaries when acting for
the Patient and shall act consistent with the
Patient’s best
interests. The known desires of the Patient expressed or evidenced
while the Patient is able to participate in medical treatment
decisions are
presumed to be in the Patient’s best interests.
g. A Patient may revoke his or her designation at any time and in
any manner sufficient to communicate an intent to revoke.
h. A
Patient Advocate may revoke his or her acceptance to the designation
at any time and in any manner sufficient to communicate an intent to
revoke.
If I am unable
to act after reasonable effort to contact me, I delegate my
authority to the person
the Patient has designated as successor
Patient Advocate. The successor Patient Advocate is
authorized to
act until I become available to act.
PATIENT
ADVOCATE
Address:
Home Phone:
Work Phone:
SUCCESSOR
PATIENT ADVOCATE
___________________________________________
Address:
Home Phone:
Work Phone:
________________