Fillable Printable 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.

(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.

(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.

(b) ____ DIRECTIVE TO WITHHOLD OR WITHDRAW TUBE FEEDING. I do not want my

life prolonged by tube feeding.

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:__________________________________"