Health Care Directive Form - Minnesota - Edit, Fill, Sign Online

MINNESOTASTATUTE §145C

HEALTHCAREDIRECTIVE

OF

_________________________________________________________________________________________________

(YourName)

I, _______________________________________________________________________, understandthisdocumentallowsmetodo

ONEORBOTHofthefollowing:

PartI:Nameanotherperson(calledthehealthcareagent)tomakehealthcaredecisionsformeifI

amunabletodecideor speakfo r myse l f. Myhealthcareagentmustmakehealthcaredecisionsfor me

basedontheinstructionsI provideinthisdocument(PartII),ifany,thewishesI havemade knownto

himorher,ormustactinmybestinterestif I havenotmademyhealthcarewishesknown.

AND/OR

PartII:

Givehealthcareinstructionstoguideothersmakinghealthcaredecisionsforme. If I have

nameda healthcareagent,theseinstructionsaretobeusedbytheagent.These instructionsmayalsobe

used by myhealthcareproviders,othersassistingwithmy healthcare,andmyfamily,intheevent I

cannotmakedecisionsformyself.

Part I: Appointment of Health Agent

ThisiswhoI wanttomakehealthcaredecisionsformeifI amunabletodecideorspeakformyself(I

knowI canchangemyagentoralternateagentatanytimeandI knowI donothavetoappointanagent

oranalternateagent).NOTE:If youappointanagent,youshoulddiscussthishealthcaredirectivewith

youragentandgiveyouragenta copy. Ifyoudo notwishtoappointanagent,youmayleavePartI

blankandgotoPartII.

When Iamunableto decideorspeakformyself,I trust and appoint____________________________________________

___________tomakehealthcare decisionsfor me. Thispersoniscalledmyhealthcareagent.

Relationshipof my health car eagenttome: __________________________________________________________________________

Telephone numberofmyhealthcareagent: ___________________________________________________________________________

Addressof my healthcareagent: ________________________________________________________________________________

_______________________________________________________________________________________________________________________________

(Optional)AppointmentofAlternateHealthCareAgent:Ifmyhealthcareagentisnotreasonablyavailable,

I trustandappoint__________________________________________tobemyhealthcareagentinstead.

Relationshipofalternatehealthcareagentto me: ____________________________________________________________________

Telephonenumberofmyalternatehealthcareagent: _________________________________________________________________

Addressofmyalternatehealthcareagent: _____________________________________________________________________________

________________________________________________________________________________________________________________________________

THIS IS WHAT I WANT MY HEALTH CARE AGENT

TO BE ABLE TO DO IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF

(I knowI canchangethesechoices)

Myhealthcareagentisautomaticallygiventhepowerslistedbelowin(A)through(D).Myhealthcare

agentmustfollowmyhealthcareinstructionsinthisdocumentoranyotherinstructionsIhavegiven

to myagent.If Ihavenotgivenhealthcareinstructions,thenmyagentmustactinmybestinterest.

WheneverI am unabletodecideorspeakformyself, myhealthcareagenthasthepower to:

(A)Makeanyhealthcaredecisionfor me. Thisincludesthepowertogive,refuse,or withdraw

consenttoanycare, treatment,service,orprocedures. Thisincludesdecidingwhethertostop

or notstarthealthcarethatiskeepingmeormightkeepmealive,anddecidingaboutintrusive

mentalhealthtreatment.

(B)Choosemyhealthcareproviders.

(C)

ChoosewhereI liveandreceivecareandsupportwhenthosechoicesrelatetomyhealthcare

needs.

(D)

Reviewmymedicalrecordsandhavethe same r ightsthat I wouldhavetogivemy

medical recordsto otherpeople.

If I DONOTwantmyhealthcareagenttohavea powerlistedabovein(A)through(D)ORifI wantto

LIMITanypowerin(A)through(D),I MUSTsaythathere:___________________________________________________

_____________________________________________________________________________________________________________________________

My healthcareagentisNOTautomaticallygiventhepowerslistedbelowin(1) and(2).IfI WANTmy

agenttohaveanyofthepowersin( 1)and(2),I mustINITIALthelineinfrontofthepower;thenmy

agentWILLHAVEthatpower.

(1)

Todecidewhethertodonateanypartsofmybody, includingorgans,tissues, andeyes,

whenI die.

(2)TodecidewhatwillhappenwithmybodywhenI die(burial,cremation).

If I wa nt tosayanythingmoreaboutmyhealthcareagent'spowersorlimitsonthepowers,I cansayit

here:

____________________________________________________________________________________

Part II: Health Care Instructions

NOTE: Co mpletethisPartIIifyouwishtogivehealthcareinstructions. If you appointedan

agentin PartI, completingthisPartIIisoptionalbutwouldbeveryhelpfultoyouragent.

However, if you chosenottoappointanagentin Part I,youMUSTcompletesomeorall o f

thisPart11 if you wishtomakea validhealthcaredirective.

Theseareinstructionsformy hea lt hcarewhenI am unabletodecideorspeakformyself. These

instructionsmustbefollowed(solongasthey addressmyneeds). THESEAREMYBELIEFS

AND VALUESABOUTMYHEALTHCARE(IknowI canchangethesechoicesorleaveanyof

them bl an k)

I wantyoutoknowthesethingsaboutmetohelpyou makedecisionsaboutmyhealthcare:

1.Mygoalsformyhealthcare:____________________________________________________________

_________________________________________________________________________________

2.My fears aboutmy health care:__________________________________________________________

_________________________________________________________________________________

3.My spiritual o r religious beliefs and traditions:_ _____________________________________________

_________________________________________________________________________________

4.My beliefs about when life would be no l onger worth living:___________________________________

_________________________________________________________________________________

5.My thoughts about how my .medica l condition mig ht affect my family:__________________________

_________________________________________________________________________________

6.(For a woman of childbearing age) My thoughts about how my heal th ca re should be handled in theevent

I am pre gna nt : _______________________________________________________________________

___________________________________________________________________________________

THIS IS WHAT I WANTAND DO NOTWANTFORMYHEALTHCARE

(Iknow I canchangethesechoicesorleaveanyofthemblank)

Many medicaltreatmentsmaybeusedtotrytoimprovemymedicalconditionortoprolong

my life.Examplesincludeartificialbreathingbya machineconnectedtoa tubeinthe

lungs, artificia lfeedingorfluidsthroughtubes,attemptstostart astoppedheart,surgeries,

dialysis, antibio tics,andbloodtransfusions. Mostmedicaltreatmentscanbe triedfora

whileandthen stoppediftheydonothelp.

I have these viewsaboutmyhealthcare inthesesituations:

(NOTE: Youcandiscussgeneralfeelings, specifictreatments,orleaveanyofthemblank)

1.If I had a reasonablechanceofrecovery, and were temporarilyunabletodecideorspeakfor

myself,I wouldwant:_____________________________________________________________

________________________________________________________________________________

2.If I weredyingandunabletodecideorspeakformyself, I wouldwant: _____________________

________________________________________________________________________________

3.If I werepermanently unconsciousandunabletodecideorspeakformyself,I wouldwant:__

_____________________________________________________________________________

4.If I werecompletely dependentonothersformycareandunab le todecideorspeakformyself,I

wouldwant:__________________________________________________________________________________

________________________________________________________________________________

5.In all circumstances,mydoctorswilltrytokeepmecomfortableandreducemypain. Thisis howI

feelaboutpainreliefifitwouldaffectmyalertnessorifitcouldshortenmylife:_____________

_____________________________________________________________________________

There are other things that I want or do not want for my health care, if possible:

1.Who I would liketo be my doctor:_________________________________________________

_____________________________________________________________________________

2.Where I would like to live to receive health care: _____________________________________

_____________________________________________________________________________

3.Where I would like to die and other wishes I have about dying:__________________________

_____________________________________________________________________________

4.My wishes about donating parts of my body when I die:________________________________

_____________________________________________________________________________

5.My wishes about what happens to my body when I die (cremation,burial):_________________

_____________________________________________________________________________

6.Anyotherthings:____________________________________________________________________________________

_______________________________________________________________________________________________________

Part III: Making The Document Legal

Thisdocumentmustbesignedby me. Italsomustbeverifiedeitherby a notarypublic(Option 1) OR

witnessedbytwowitnesses(Option2). Itmustbedatedwhenitisverifiedorwitnessed.

Iamthinkingclearly, Iagreewitheverythingthatiswritten inthisdocument, and Ihavemade

thisdocumentwillingly.

________________________________________________________

Mysignature

If I cannotsignmy name,Icanasksomeone

tosignthisdocumentforme.

Datesigned:

Dateofbirth: _______________________

Address: ___________________________________________________________________________

_______________________________________________________

________________________________________________________________________________________________________

SignatureofpersonwhoI askedto

signthisdocumentforme

PrintednameofpersonwhoI askedto

signthisdocumentforme

Option 1: Notary Public

Inmypresenceon____________________(date), _____________________________________(name)

acknowledgedhis/her signatureonthisdocumentoracknowledgedthat he/she authorizedthe

personsigningthisdocumenttosignonhis/herbehalf.I amnotnamedasa healthcareagentor

alternatehealthcareagentinthis document.

Subscribedandsworntobefore me this

_______ dayof_____________, _______.

___________________________________

NotaryPublic

Option 2: Two Witnesses

Twowitnessmustsign. Onlyoneofthetwowitnessescanbe ahealthcareprovider oran

employeeof a healthcareprovidergivingdirectcaretomeonthedayIsignthisdocument.

WitnessOne:

(i)

Inmypresenceon__________ (date),________________________________(name)

acknowledgedhis/hersignatureonthisdocumentoracknowledgedthathe/she

authorized thepersonsigningthisdocumenttosignonhis/herbehalf.

(ii)

I amatleast18yearsofage.

(iii)

I amnotnamed asa healthcareagentoranalternate health careagentinthis document.

(iv)If I ama healthcareprovideroranemployeeofa healthcareprovidergivingdirectcare

tothepersonlistedabovein(i),Imustinitialthisbox:[ ]

Icertifythattheinformationin(i)through(iv)istrueandcorrect.

________________________________________________________

(SignatureofWitnessOne)

Address: ________________________________________________________________________________________________________

_______________________________________________________________________________________________________

WitnessTwo:

(i)Inmypresenceon __________ (date), ________________________________(name)

acknowledgedhis/hersignatureonthisdocumentoracknowledgedthathe/she

authorized thepersonsigningthisdocumenttosignonhis/herbehalf.

(ii)I amatleast18yearsofage.

(iii)I amnotnamed asa healthcareagentoranalternate health careagentinthis document.

(iv)If Iama healthcareprovideroranemployeeofa healthcareprovidergivingdirectcare

tothepersonlistedabovein(i), I mustinitialthisbox:[ ]

I certifythattheinformationin(i)through(iv)istrueandcorrect.

________________________________________________________

(SignatureofWitnessTwo)

Address: ________________________________________________________________________________________________________

_______________________________________________________________________________________________________

REMINDER:Keepthisdocumentwithyourpersonalpapersina safeplace(notina safe

depositbox). Givesignedcopiestoyourdoctors,family, closefriends,health

careagent,andalternatehealthcareagent. Makesureyourdoctoris willing

to followyourwishes. Thisdocumentshouldbepartofyourmedicalrecord

at you r physician'sofficeandatthehospital, homecareagency,hospice, or

nursing facilitywhereyoureceiveyourcare.

Fillable Printable Health Care Directive Form - Minnesota

Fillable Printable Health Care Directive Form - Minnesota

Health Care Directive Form - Minnesota