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Fillable Printable Health Care Power of Attorney Example - South Carolina

Fillable Printable Health Care Power of Attorney Example - South Carolina

Health Care Power of Attorney Example - South Carolina

Health Care Power of Attorney Example - South Carolina

APPENDIX 2
HEALTH CARE POWER OF ATTORNEY
A health care power of attorney executed on or after January 1, 2007 must be substantially
in the following form (S. C. Code Section 62-5-504 (D):
INFORMATION ABOUT THIS DOCUMENT
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT,
YOU SHOULD KNOW THESE IMPORTANT FACTS:
1. THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR AGENT THE
POWER TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU CANNOT MAKE THE
DECISION FOR YOURSELF. THIS POWER INCLUDES THE POWER TO MAKE
DECISIONS ABOUT LIFE-SUSTAINING TREATMENT. UNLESS YOU STATE
OTHERWISE, YOUR AGENT WILL HAVE THE SAME AUTHORITY TO MAKE
DECISIONS ABOUT YOUR HEALTH CARE AS YOU WOULD HAVE.
2. THIS POWER IS SUBJECT TO ANY LIMITATIONS OR STATEMENTS OF YOUR
DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. YOU M AY STATE IN THIS
DOCUMENT ANY TREATMENT YOU DO NOT DESIRE OR TREATMENT YOU WANT
TO BE SURE YOU RECEIVE. YOUR AGENT WILL BE OBLIGATED TO FOLLOW YOUR
INSTRUCTIONS WHEN MAKING DECISIONS ON YOUR BEHALF. YOU MAY ATTACH
ADDITIONAL PAGES IF YOU NEED MORE SPACE TO COMPLETE THE STATEMENT.
3. AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE
HEALTH CARE DECISIONS FOR YOURSELF IF YOU ARE MENTALLY COMPETENT
TO DO SO. AFTER YOU HAVE SIGNED THIS DOCUMENT, NO TREATMENT MAY BE
GIVEN TO YOU OR STOPPED OVER YOUR OBJECTION IF YOU ARE MENTALLY
COMPETENT TO MAKE THAT DECISION.
4. YOU HAVE THE RIGHT TO REVOKE THIS DOCUMENT, AND TERMINATE YOUR
AGENT'S AUTHORITY, BY INFORMING EITHER YOUR AGENT OR YOUR HEALTH
CARE PROVIDER ORALLY OR IN WRITING.
5. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A SOCIAL WORKER, LAWYER, OR OT HER
PERSON TO EXPLAIN IT TO YOU.
6. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS TWO PERSONS SIGN
AS WITNESSES. EACH OF THESE PERSONS MUST EITHER WITNESS YOUR SIGNING
OF THE POWER OF ATTORNEY OR WITNESS YOUR ACKNOWLEDGMENT THAT
THE SIGNATURE ON THE POWER OF ATTORNEY IS YOURS.
THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:
A. YOUR SPOUSE, YOUR CHILDREN, GRANDCHILDREN, AND OTHER LINEAL
DESCENDANTS; YOUR PARENTS, GRANDPARENTS, AND OTHER LINEAL
ANCESTORS; YOUR SIBLINGS AND THEIR LINEAL DESCENDANTS; OR A SPOUSE
OF ANY OF THESE PERSONS.
B. A PERSON WHO IS DIRECTLY FINANCIALLY RESPONSIBLE FOR YOUR
MEDICAL CARE.
C. A PERSON WHO IS NAMED IN YOUR WILL, OR, IF YOU HAVE NO WILL, WHO
WOULD INHERIT YOUR PROPERTY BY INTESTATE SUCCESSION.
D. A BENEFICIARY OF A LIFE INSURANCE POLICY ON YOUR LIFE.
E. THE PERSONS NAMED IN THE HEALTH CARE PO WER OF ATTORNE Y AS YOUR
AGENT OR SUCCESSOR AGENT.
F. YOUR PHYSICIAN OR AN EMPLOYEE OF YOUR PHYSICIAN.
G. ANY PERSON WHO WOULD HAVE A CLAIM AGAINST ANY PORTION OF YOUR
ESTATE (PERSONS TO WHOM YOU OWE MONEY).
IF YOU ARE A PATIENT IN A HEALTH FACILITY, NO MORE THAN ONE WITNESS
MAY BE AN EMPLOYEE OF THAT FACILITY.
7. YOUR AGENT MUST BE A PERSON WHO IS 18 YEARS OLD OR OLDER AND OF
SOUND MIND. IT MAY NOT BE YOUR DOCTOR OR ANY OTHER HEALTH CARE
PROVIDER THAT IS NOW PROVIDING YOU WITH TREATMENT; OR AN EMPLOYEE
OF YOUR DOCTOR OR PROVIDER; OR A SPOUSE OF THE DOCTOR, PR OVIDER, OR
EMPLOYEE; UNLESS THE PERSON IS A RELATIVE OF YOURS.
8. YOU SHOULD INFORM THE PERSON THAT YOU WANT HIM OR HER TO BE
YOUR HEALTH CARE AGENT. YOU SHOULD DIS CUSS THIS DOCUMENT WITH
YOUR AGENT AND YOUR PHYSICIAN AND GIVE EACH A SIGNED COPY. IF YOU
ARE IN A HEALTH CARE FACILITY OR A NURSING CARE FACILITY, A COPY OF
THIS DOCUMENT SHOULD BE INCLUDED IN YOUR MEDICAL RECORD.
HEALTH CARE POWER OF ATTORNEY
(S.C. STATUTORY FORM)
1. DESIGNATION OF HEALTH CARE AGENT
I, __________, hereby appoint:
(Principal)
(Agent's Name) _____________________________________
(Agent's Address) ___________________________________
Telephone: home: _________ work: __________ mobile:______
as my agent to make health care decisions for me as authorized in this document.
Successor Agent: If an agent named by me dies, becomes legally disabled, resigns, refuses to act,
becomes unavailable, or if an agent who is my spouse is divorced or separated from me, I name
the following as successors to my agent, each to act alone and successively, in the order named:
a. First Alternate Agent:
Address: __________________________________
Telephone: home:______ work:_______ mobile:______
b. Second Alternate Agent:
Address:_______________________________________
Telephone: home:______ work:_______ mobile:______
Unavailability of Agent(s): If at any relevant time the agent or successor agents named here are
unable or unwilling to make decisions concerning my health care, and those decisions are to be
made by a guardian, by the Probate Court, or by a surrogate pursuant to the Adult Health Care
Consent Act, it is my intention that the guardian, Probate Court, or surrogate make those
decisions in accordance with my directi ons as stated in this document.
2. EFFECTIVE DATE AND DURABILITY
By this document I intend to create a durable power of attorney effective upon, and only during,
any period of mental incompetence, except as provided in Paragraph 3 below.
3. HIPAA AUTHORIZATION
When considering or making health care decisions for me, all individually identifiable health
information and medical records shall be released without restriction to my health care agent(s)
and/or my alternate health care agent(s) named above including, but not limited to, (i) diagnostic,
treatment, other health care, and related insurance and financial records and information
associated with any past, present, or future physical or m ental health condition including, but not
limited to, diagnosis or treatment of HIV/AIDS, sexually transmitted disease(s), mental illness,
and/or drug or alcohol abuse and (ii) any written opinion relating to my health that su ch health
care agent(s) and/or alternate health care agent(s) may have requested. Without limiting the
generality of the foregoing, this release authority applies to all health information and medical
records governed by the Health Information Portability and Accountability Act of 1996
(HIPAA), 42 USC 1320d and 45 CFR 160-164; is effective whether or not I am mentally
competent; has no expiration date; and shall terminate only in the event that I revoke the
authority in writing and deliver it to my health care provider.
4. AGENT'S POWERS
I grant to my agent full authority to make d ecisions for me regarding my health care. In
exercising this authority, my agent shall follow my desires as stated in this document or
otherwise expressed by me or known to my agent. In making any decision, my agent shall
attempt to discuss the proposed decision with me to determine my desires if I am able to
communicate in any way. If my agent cannot determine the choice I would want made, then my
agent shall make a choice for me based upon what my agent believes to be in my best interests.
My agent's authority to interpret my desires is intended to be as broad as possible, except for any
limitations I may state below.
Accordingly, unless specifically limited by the provisions specified below, my agent is
authorized as follows:
A. To consent, refuse, or withdraw consent to any and all types of medical care, treatment,
surgical procedures, diagnostic procedures, medication, and the use of mechanical or other
procedures that affect any bodily function, including, but not limited to, artificial respiration,
nutritional support and hydration, and cardiopulmonary resuscitation;
B. To authorize, or refuse to authorize, any medication or procedure intended to relieve pain,
even though such use may lead to physical damage, addiction, or hasten the moment of, but not
intentionally cause, my death;
C. To authorize my admission to or discharge, even against medical advice, from any
hospital, nursing care facility, or similar facility or service;
D. To take any other action necessary to making, documenting, and assuring implementation
of decisions concerning my health care, including, but not limited to, granting any waiver or
release from liability required by any hospital, physician, nursing care provider, or other health
care provider; signing any documents relating to refusals of treatment or the leaving of a facility
against medical advice, and pursuing any legal action in my name, and at the expense of my
estate to force compliance with my wishes as determined by my agent, or to seek actual or
punitive damages for the failure to comply.
E. The powers granted above do not include the following powers or are subject to the
following rules or limitations:
_______________________________________________________
_______________________________________________________
_______________________________________________________
5. ORGAN DONATION (INITIAL ONLY ONE)
My agent may ___; may not ___ consent to the donation of all or any of my tissue or organs for
purposes of transplantation.
6. EFFECT ON DECLARATION OF A DESIRE FOR A NATURAL DEATH (LIVING
WILL)
I understand that if I have a valid Declaration of a Desire for a Natural Death, the instructions
contained in the Declaration will be given effect in any situation to which they are applicable.
My agent will have authority to make decisions concerning my health care only in situations to
which the Declaration does not apply.
7. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING TREATMENT
With respect to any Life-Sustaining Treatment, I direct the following:
(INITIAL ONLY ONE OF THE FOLLOWING 3 PARAGRAPHS)
(1) ___ GRANT OF DISCRETION TO AGENT. I do not want my life to be prolonged nor do
I want life-sustaining treatment to be provided or continued if my agent believes the burdens of
the treatment outweigh the expected benefits. I want my agent to consider the relief of suffering,
my personal beliefs, the expense involved and the quality as well as the possible extension of my
life in making decisions concerning life-sustaining treatment.
OR
(2) ___ DIRECTIVE TO WITHHOLD OR WITHDRAW TREATMENT. I do not want my
life to be prolonged and I do not want life-sustaining treatment:
a. if I have a condition that is incurable or irreversible and, without the administration of life-
sustaining procedures, expected to result in death within a relatively short period of time; or
b. if I am in a state of permanent unconsciousness.
OR
(3) ___ DIRECTIVE FOR MAXIMUM TREATMENT. I want my life to be prolonged to the
greatest extent possible, within the standards of accepted medical practice, without regard to my
condition, the chances I have for recovery, or the cost of the procedures.
8. STATEMENT OF DESIRES REGARDING TUBE FEEDING
With respect to Nutrition and Hydration provided by means of a nasogastric tube or tube into the
stomach, intestines, or veins, I wish to make clear that in situations where life-sustaining
treatment is being withheld or withdrawn pursuant to Item 7, (INITIAL ONLY ONE OF
THE FOLLOWING THREE PARAGRAPHS):
(a) ____ GRANT OF DISCRETION TO AGENT. I do not want my life to be prolonged by tube
feeding if my agent believes the burdens of tube feeding outweigh the expected benefits. I want
my agent to consider the relief of suffering, my personal beliefs, the expense involved, and the
quality as well as the possible extension of my life in making this decision.
OR
(b) ____ DIRECTIVE TO WITHHOLD OR WITHDRAW TUBE FEEDING. I do not want my
life prolonged by tube feeding.
OR
(c) ____DIRECTIVE FOR PROVISION OF TUBE FEEDING. I want tube feeding to be
provided within the standards of accepted medical practice, without regard to my condition, the
chances I have for recovery, or the cost of the procedure, and without regard to whether other
forms of life-sustaining treatment are being withheld or withdrawn.
IF YOU DO NOT INITIAL ANY OF THE STATEMENTS IN ITEM 8, YOUR AGENT WILL
NOT HAVE AUTHORITY TO DIRECT THAT NUTRITION AND HYDRATION
NECESSARY FOR COMFORT CARE OR ALLEVIATION OF PAIN BE WITHDRAWN.
9. ADMINISTRATIVE PROVISIONS
A. I revoke any prior Health Care Power of Attorney and any provisions relating to health care
of any other prior power of attorney.
B. This power of attorney is intended to be valid in any jurisdiction in which it is presented.
BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE CONTENTS OF THIS
DOCUMENT AND THE EFFECT OF THIS GRANT OF POWERS TO MY AGENT.
I sign my name to this Health Care Power of Attorney on
this ___ day of ___, 20 __. My current home address is:
_________________________________________________________
Principal's Signature:______________________________________
Print Name of Principal:____________________________________
I declare, on the basis of information and belief, that the person who signed or acknowledged this
document (the principal) is personally known to me, that he/she signed or acknowledged this
Health Care Power of Attorney in my presence, and that he/she appears to be of sound mind and
under no duress, fraud, or undue influence. I am not related to the principal by blood, m arriage,
or adoption, either as a spouse, a lineal ancestor, descendant of the parents of the principal, or
spouse of any of them. I am not directly financially responsible for the principal's medical care. I
am not entitled to any portion of the principal's estate upon his decease, whether under any will
or as an heir by intestate succession, nor am I the beneficiary of an insurance policy on the
principal's life, nor do I have a claim against the principal's estate as of this time. I am not the
principal's attending physician, nor an employee of the attending physician. No more than one
witness is an employee of a health facility in which the principal is a patient. I am not appointed
as Health Care Agent or Successor Health Care Agent by this document.
Witness No. 1
Signature:_____________________________ Date:____________
Print Name:_________________________ Telephone:__________
Address:_______________________________________________
______________________________________________________
Witness No. 2
Signature:_____________________________ Date:____________
Print Name:___________________________ Telephone:________
Address:_______________________________________________
______________________________________________________
(This portion of the document is optional and is not required to create a valid health care power
of attorney.)
STATE OF SOUTH CAROLINA
COUNTY OF___________________________________________
The foregoing instrument was acknowledged before me by Principal on ________________, 20
___________.
Notary Public for South Carolina____________________________
My Commission Expires:__________________________________"
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