Fillable Printable Durable Power of Attorney for Health Care Example - Idaho

Durable Power of Attorney for Health Care Example - Idaho

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SECTION II:

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

and Personal Instructions

(IRC Title 39: Ch.45: §39-4508 to §39-4514)

15. INTRODUCTION: This section lets you name a person (called an “agent” or “attorney-in-

fact”) to make health care decisions for you, if you cannot make them for yourself. The

person you name must be at least 18 years of age. Unless you indicate otherwise, the

powers which you may grant through this document include the authority to make health

care decisions, including life-sustaining treatment decisions, as well as other authorities

regarding related affairs. If you have questions, you should seek further counsel and

advice.

Creation of Durable Power of Attorney for Health Care

16. Be it known that I:

Full Legal Name: ______________________________________________________

Date of Birth: _________________________________________________________

Street Address: ________________________________________________________

City: ______________________________ County: __________________________

State: ______________________________ Zip Code: ________________________

~~ Intend by this document to create a durable power of attorney for health care. This

power of attorney shall not be affected by my later disability, incompetency, or incapacity

(as the “principal” herein). I am of sound mind, and state that execution of this document

is voluntary and without duress. Creation of this power of attorney is for the purpose of

designating someone to act as my health care agent (also known as my attorney-in-fact),

to act in my place to make medical decisions for me if I become unable to make them for

myself . It also grants my agent the authority to make all legal and personal care

decisions that I could make for myself, unless otherwise limited in this document. This

designation is effective when, in the opinion of at least one licensed medical doctor who

has personally examined me, I am no longer able make treatment decisions for myself.

By creating this document I revoke any prior power of attorney for health care.

Designation of Health Care Agent:

17. I understand that I am not required to choose an agent, but that I am advised to do so to

ensure that my wishes are fully represented and followed. Therefore:

(initial only one)

_____ I do not want to choose a health care agent at this time (or I have no one

appropriate for the task). However, I instruct that Section I of this document be

recognized as a declaration of my wishes within this Advance Health Care

Directive (proceed now to sign on page 7);

OR,

_____ I do wish to appoint a health care agent. I recognize that, by Idaho law, this person

may not be my treating health care provider nor a non-relative employee of my

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health care provider; nor may my agent be an operator of a community care

facility or a non-relative employee of such an operator. The person I have chosen

to act as my agent and to whom I give full authority to make all medical and

health care decisions for me at any time during which I am unable to make them

for myself, is:

18. Name of Agent: __________________________________________________

Address: ________________________________________________________

Telephone: Home:_____________________ Work:______________________

Cell Phone or Pager: ___________________ E-mail: ____________________

19. If for any reason I revoke the authority of my agent, or this individual is unavailable,

unwilling, or otherwise ineligible to make decisions for me, the following individuals (to

act alone and successively, in order of priority as listed) are authorized to serve as

alternate agents:

20. Name of Alternate #1:_____________________________________________

Address: ________________________________________________________

Telephone: Home:_____________________ Work:______________________

Cell Phone or Pager: ___________________ E-mail: ____________________

21. Name of Alternate #2: ____________________________________________

Address: ________________________________________________________

Telephone: Home:_____________________ Work:______________________

Cell Phone or Pager: ___________________ E-mail: ____________________

22. Each alternate successor designated shall be vested with the same power and duties as if

originally named as my health care agent. These persons, in priority of the order

presented, are to have binding authority over any and all other persons to make my

personal and health care decisions.

Decision-Making Guidelines

23. In making decisions in my behalf if my wishes are not otherwise clear (see my living will), I

direct my agent to act in his/her best understanding of what my wishes would have been.

And, where not reasonably sure of what I would have wanted, to act according to his/her

belief in my interests as determined from his/her knowledge of my personal and family

affairs, and other goals and values in life. The authority of my agent shall not be

terminated unless it appears that he or she is clearly and obviously not acting in

accordance with my known wishes, or is overwhelmingly ignoring my best interests if my

wishes are not otherwise known.

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Specific Authorities, Powers and Provisions

24. This appointment shall extend to (but not be limited to) the following powers and authorities

(initial beside any power or authority you wish to include):

A. _____ Consent, refuse consent, renew or withdraw consent to any treatment, tests,

medications, care, services, surgery or therapies used to diagnose or treat any

physical or mental condition. This authorization includes the authority to consent

to the provision, withholding or withdrawal of any life-sustaining treatment or

procedure even if the consent or refusal of such will result in my death; and to

legally act in every other matter related to my health and personal care with that

same authority I would have, without incurring any personal, legal or financial

liability for such.

B. _____ Sign, execute, deliver, and acknowledge any contract or other document that

may be necessary, desirable, convenient, or proper in order to exercise and carry

out my wishes and any of the powers as described in this document. This shall

include “refusal of treatment” forms, and “discharge against medical advice”

forms.

C. _____ Request, review, receive, and disclose any medical information, verbal or

written, needed to follow and manage my physical or mental health treatment and

general care, and to authorize the release of my medical records or any other

documentation needed to continue my treatment in or outside of any health care

setting or service. This release authority applies to any information governed by

the Health Insurance Portability and Accountability Act of 1996 (HIPPA), 42

U.S.C. 1320d and 45 CFR 160 through 164.

D. _____ Consent to organ and/or tissue donation (or to donate my entire remains for

medical or scientific research if I have indicated this is my wish).

(Any limitations or exclusions to your agent’s authority should be noted below)

Additional Statement of Desires, Special Provisions, and Limitations.

25. Noted below are any added limitations or other provisions which my health care agent must

follow in acting in his or her representative capacity:

26. Living Will Declaration incorporation (if completed) and agent instructions (if

appointed): I intend for my agent to follow, incorporate and enforce as medical

and attorney-in-fact directives, any and all wishes as outlined in the Living Will

Declaration contained in this advance directive document.

27. Other Wishes, Provisions, Treatments, and/or Limitations: _________________

________________________________________________________________

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Statement and Signature of Principal/grantor

28. This document is governed by Idaho law, although I request that it be honored in any state in

which I may be found.

By signing below, I indicate that I am fully aware of the contents of this document, and

understand its purpose, effect, consequences, and full import. Further, I am of legal age, and I

am emotionally and mentally competent to complete this document. I am acting voluntarily and

without fraud, duress or undue influence.

(You should sign in the presence of two qualified witnesses or a notary; see below)

29. Signed:__________________________________ Date: ______________________

At: (City) _______________________________ (State) _____________________

30. Signature Assistance: Have the following completed, only if you (the “principal”)

are physically unable to sign: The principal’s name, above (and/or elsewhere

within this document), was signed at his/her direction and in the presence of the

principal and two witnesses, by the person whose signature and name appear

below:

31. Signature of Assistant: ____________________________________________

Printed Name:_______________________ Date: ______________________

Address: _______________________________________________________

Telephone: Home: ___________________ Work: _____________________

Statement of Witnesses

32. I am at least 18 years of age and I know the principal personally or have been

provided convincing evidence of identity. The principal has affixed (or caused to be

affixed) his/her signature or mark in my presence. It appears that this document is being

executed voluntarily, and the principal appears to be of sound mind and under no duress,

fraud, or undue influence. I have not signed the principal’s signature (above) for or at the

direction of the principal. I declare under penalty of perjury that I am not related to the

principal by blood, marriage, or adoption, nor am I directly responsible for his or her

medical care or costs. I am not the agent or an alternate or successor named in this

document. Further, I am not the attending physician or other treating health care

provider, nor an employee of the physician or other health care provider. Nor am I an

operator of a community care facility nor an employee of such, nor a party to any parent

organization thereof. I am also not the employee of a life or health insurance provider for

he principal, nor am I involved in directly physically caring for the principal, and to the

best of my knowledge I have no claim against nor am I entitled to any part of the

principal’s estate upon his or her death under a will or codicil now existing, nor by any

other operation of law.

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33. 1 Witness: _________________________________________________________

(Signature)

_________________________________ _____________________

(Name Printed) (Date)

_________________________________________________________

(Residence Address)

34. 2 Witness: _________________________________________________________

(Signature)

_________________________________ _____________________

(Name Printed) (Date)

_________________________________________________________

(Residence Address)

Certificate of Acknowledgment of Notary Public:

35. State of

Idaho

County of_______________________

}

On this_______day of ____________________________, in the year______, before me

(insert

officer name/title)

: _________________________________, personally appeared

(insert name of

Principal on line here)

:______________________________, personally known to me (or proved to

me on the basis of satisfactory evidence (describe: _____________________)) to be the person(s)

whose name is subscribed to this/these instrument(s) and acknowledged to me that he/she

executed the same in his/her authorized capacity, and that by his/her signature on the

instrument(s), executed the instrument(s). I declare that he/she appears of sound mind and not

under or subject to duress, fraud, or undue influence, that he/she acknowledges the execution of

the same to be his/her voluntary act and deed, and that I am not the agent (attorney-in-fact),

proxy, surrogate, or a successor of any such, as designated within this document, nor do I hold

any interest in his/her estate through a Will or by other operation of law.

WITNESS my hand and official seal.

__________________________________ Notary Seal:

Signature of Notary Public

__________________________________

Date Commission Expires