Fillable Printable Health Care Power of Attorney Form - North Carolina

Health Care Power of Attorney Form - North Carolina

HEALTH CARE POWER OF ATTORNEY

NOTE: YOU SHOULD USE THIS DOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE

AGENT IF YOU ARE COMFORTABLE GIVING THAT PERSON BROAD AND SWEEPING POWERS

TO MAKE HEALTH CARE DECISIONS FOR YOU. THERE IS NO LEGAL REQUIREMENT THAT

ANYONE EXECUTE A HEALTH CARE POWER OF ATTORNEY.

EXPLANATION: You have the right to name someone to make health care decisions for you when you

cannot make or communicate those decisions. This form may be used to create a health care power of

attorney, and meets the requirements of North Carolina law. However, you are not required to use this

form, and North Carolina law allows the use of other forms that meet certain requirements. If you prepare

your own health care power of attorney, you should be very careful to make sure it is consistent with

North Carolina law.

This document gives the person you designate as your health care agent broad powers to make health

care decisions for you when you cannot make the decision yourself or cannot communicate your decision

to other people. You should discuss your wishes concerning life-prolonging measures, mental health

treatment, and other health care decisions with your health care agent. Except to the extent that you

express specific limitations or restrictions in this form, your health care agent may make any health care

decision you could make yourself.

This form does not impose a duty on your health care agent to exercise granted powers, but when a

power is exercised, your health care agent will be obligated to use due care to act in your best interests

and in accordance with this document.

This Health Care Power of Attorney form is intended to be valid in any jurisdiction in which it is presented,

but places outside North Carolina may impose requirements that this form does not meet.

If you want to use this form, you must complete it, sign it, and have your signature witnessed by two

qualified witnesses and proved by a notary public. Follow the instructions about which choices you can

initial very carefully. Do not sign this form until two witnesses and a notary public are present to watch

you sign it. You then should give a copy to your health care agent and to any alternates you name. You

should consider filing it with the Advance Health Care Directive Registry maintained by the North Carolina

Secretary of State: http://www.nclifelinks.org/ahcdr/

1. Designation of Health Care Agent.

I, _____________________, being of sound mind, hereby appoint the following person(s) to serve as my

health care agent(s) to act for me and in my name (in any way I could act in person) to make health care

decisions for me as authorized in this document. My designated health care agent(s) shall serve alone,

in the order named.

A. Name:

Home Telephone:

Home Address:

Work Telephone:

Cellular Telephone:

B. Name:

Home Telephone:

Home Address:

Work Telephone:

Cellular Telephone:

C. Name:

Home Telephone:

Home Address:

Work Telephone:

Cellular Telephone:

Any successor health care agent designated shall be vested with the same power and duties as if

originally named as my health care agent, and shall serve any time his or her predecessor is not

reasonably available or is unwilling or unable to serve in that capacity.

2. Effectiveness of Appointment.

My designation of a health care agent expires only when I revoke it. Absent revocation, the authority

granted in this document shall become effective when and if one of the physician(s) listed below

determines that I lack capacity to make or communicate decisions relating to my health care, and will

continue in effect during that incapacity, or until my death, except if I authorize my health care agent to

exercise my rights with respect to anatomical gifts, autopsy, or disposition of my remains, this authority

will continue after my death to the extent necessary to exercise that authority.

(Physician)

If I have not designated a physician, or no physician(s) named above is reasonably available, the

determination that I lack capacity to make or communicate decisions relating to my health care shall be

made by my attending physician.

3. Revocation.

Any time while I am competent, I may revoke this power of attorney in a writing I sign or by

communicating my intent to revoke, in any clear and consistent manner, to my health care agent or my

health care provider.

4. General Statement of Authority Granted.

Subject to any restrictions set forth in Section 5 below, I grant to my health care agent full power and

authority to make and carry out all health care decisions for me. These decisions include, but are not

limited to:

A. Requesting, reviewing, and receiving any information, verbal or written, regarding my physical or

mental health, including, but not limited to, medical and hospital records, and to consent to the

disclosure of this information.

B. Employing or discharging my health care providers.

C. Consenting to and authorizing my admission to and discharge from a hospital, nursing or

convalescent home, hospice, long-term care facility, or other health care facility.

D. Consenting to and authorizing my admission to and retention in a facility for the care or treatment

of mental illness.

E. Consenting to and authorizing the administration of medications for mental health treatment and

electroconvulsive treatment (ECT) commonly referred to as “shock treatment.”

F. Giving consent for, withdrawing consent for, or withholding consent for, X-ray, anesthesia,

medication, surgery, and all other diagnostic and treatment procedures ordered by or under the

authorization of a licensed physician, dentist, podiatrist, or other health care provider. This

authorization specifically includes the power to consent to measures for relief of pain.

G. Authorizing the withholding or withdrawal of life-prolonging measures.

H. Providing my medical information at the request of any individual acting as my attorney-in-fact

under a durable power of attorney or as a Trustee or successor Trustee under any Trust

Agreement of which I am a Grantor or Trustee, or at the request of any other individual whom my

health care agent believes should have such information. I desire that such information be

provided whenever it would expedite the prompt and proper handling of my affairs or the affairs of

any person or entity for which I have some responsibility. In addition, I authorize my health care

agent to take any and all legal steps necessary to ensure compliance with my instructions

providing access to my protected health information. Such steps shall include resorting to any

and all legal procedures in and out of courts as may be necessary to enforce my rights under the

law and shall include attempting to recover attorneys’ fees against anyone who does not comply

with this health care power of attorney.

I. To the extent I have not already made valid and enforceable arrangements during my lifetime that

have not been revoked, exercising any right I may have to authorize an autopsy or direct the

disposition of my remains.

J. Taking any lawful actions that may be necessary to carry out these decisions, including but not

limited to: (i) signing, executing, delivering, and acknowledging any agreement, release,

authorization, or other document that may be necessary, desirable, convenient, or proper in order

to exercise and carry out any of these powers; (ii) granting releases of liability to medical

providers or others; and (iii) incurring reasonable costs on my behalf related to exercising these

powers, provided that this health care power of attorney shall not give my health care agent

general authority over my property or financial affairs.

5. Special Provisions and Limitations.

(Notice: The authority granted in this document is intended to be as broad as possible so that your health

care agent will have authority to make any decisions you could make to obtain or terminate any type of

health care treatment or service. If you wish to limit the scope of your health care agent’s powers, you

may do so in this section. If none of the following are initialed, there will be no special limitations on your

agent’s authority.)

A. Limitations about Artificial Nutrition or Hydration: In exercising the authority to

make health care decisions on my behalf, my health care agent:

(Initial)

shall NOT have the authority to withhold artificial nutrition (such as through tubes)

OR may exercise that authority only in accordance with the following special

provisions:

(Initial)

shall NOT have the authority to withhold artificial hydration (such as through tubes)

OR may exercise that authority only in accordance with the following special

provisions:

NOTE: If you initial either block but do not insert any special provisions, your

health care agent shall have NO AUTHORITY to withhold artificial nutrition or

hydration.

(Initial)

B. Limitations Concerning Health Care Decisions. In exercising the authority to make

health care decisions on my behalf, the authority of my health care agent is subject

to the following special provisions: [Here you may include any specific provisions

you deem appropriate such as: your own definition of when life-prolonging

measures should be withheld or discontinued, or instructions to refuse any specific

types of treatment that are inconsistent with your religious beliefs, or are

unacceptable to you for any other reason.]

NOTE: DO NOT initial unless you insert a limitation.

(Initial)

C. Limitations Concerning Mental Health Decisions. In exercising the authority to

make mental health decisions on my behalf, the authority of my health care agent is

subject to the following special provisions: [Here you may include any specific

provisions you deem appropriate such as: limiting the grant of authority to make

only mental health treatment decisions, your own instructions regarding the

administration or withholding of psychotropic medications and electroconvulsive

treatment (ECT), instructions regarding your admission to and retention in a health

care facility for mental health treatment, or instructions to refuse any specific types

of treatment that are unacceptable to you.]

NOTE: DO NOT initial unless you insert a limitation.

(Initial)

D. Advance Instruction for Mental Health Treatment. [Notice: This health care power

of attorney may incorporate or be combined with an advance instruction for mental

health treatment, executed in accordance with Part 2 of Article 3 of Chapter 122C of

the General Statutes, which you may use to state your instructions regarding mental

health treatment in the event you lack capacity to make or communicate mental

health treatment decisions. Because your health care agent’s decisions must be

consistent with any statements you have expressed in an advance instruction, you

should indicate here whether you have executed an advance instruction for mental

health treatment]:

NOTE: DO NOT initial unless you insert an indication.

(Initial)

E. Autopsy and Disposition of Remains. In exercising the authority to make decisions

regarding autopsy and disposition of remains on my behalf, the authority of my

health care agent is subject to the following special provisions and limitations.

(Here you may include any specific limitations you deem appropriate such as:

limiting the grant of authority and the scope of authority, or instructions regarding

burial or cremation):

NOTE: DO NOT initial unless you insert a limitation.

6. Organ Donation.

To the extent I have not already made valid and enforceable arrangements during my lifetime that have

not been revoked, my health care agent may exercise any right I may have to:

(Initial)

donate any needed organs or parts; or

(Initial)

donate only the following organs or parts:

_____________________________________________________________

NOTE: DO NOT INITIAL BOTH BLOCKS ABOVE.

(Initial)

donate my body for anatomical study if needed.

(Initial)

In exercising the authority to make donations, my health care agent is subject

to the following special provisions and limitations: (Here you may include any

specific limitations you deem appropriate such as: limiting the grant of

authority and the scope of authority, or instructions regarding gifts of the body

or body parts):

_______________________________________________________

NOTE: DO NOT initial unless you insert a limitation.

NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN THIS INSTRUMENT

WITHOUT YOUR INITIALS.

7. Guardianship Provision.

If it becomes necessary for a court to appoint a guardian of my person, I nominate the persons

designated in Section 1, in the order named, to be the guardian of my person, to serve without bond

or security. The guardian shall act consistently with G.S. 35A-1201(a)(5).

8. Reliance of Third Parties on Health Care Agent.

A. No person who relies in good faith upon the authority of or any representations by my health care

agent shall be liable to me, my estate, my heirs, successors, assigns, or personal

representatives, for actions or omissions in reliance on that authority or those representations.

B. The powers conferred on my health care agent by this document may be exercised by my health

care agent alone, and my health care agent's signature or action taken under the authority

granted in this document may be accepted by persons as fully authorized by me and with the

same force and effect as if I were personally present, competent, and acting on my own behalf.

All acts performed in good faith by my health care agent pursuant to this power of attorney are

done with my consent and shall have the same validity and effect as if I were present and

exercised the powers myself, and shall inure to the benefit of and bind me, my estate, my heirs,

successors, assigns, and personal representatives. The authority of my health care agent

pursuant to this power of attorney shall be superior to and binding upon my family, relatives,

friends, and others.

9. Miscellaneous Provisions.

A. Revocation of Prior Powers of Attorney. I revoke any prior health care power of attorney. The

preceding sentence is not intended to revoke any general powers of attorney, some of the

provisions of which may relate to health care; however, this power of attorney shall take

precedence over any health care provisions in any valid general power of attorney I have not

revoked.

B. Jurisdiction, Severability and Durability. This Health Care Power of Attorney is intended to be

valid in any jurisdiction in which it is presented. The powers delegated under this power of

attorney are severable, so that the invalidity of one or more powers shall not affect any others.

This power of attorney shall not be affected or revoked by my incapacity or mental incompetence.

C. Health Care Agent Not Liable. My health care agent and my health care agent's estate, heirs,

successors, and assigns are hereby released and forever discharged by me, my estate, my heirs,

successors, assigns and personal representatives from all liability and from all claims or demands

of all kinds arising out of my health care agent's acts or omissions, except for my health care

agent’s willful misconduct or gross negligence.

D. No Civil or Criminal Liability. No act or omission of my health care agent, or of any other person,

entity, institution, or facility acting in good faith in reliance on the authority of my health care agent

pursuant to this Health Care Power of Attorney shall be considered suicide, nor the cause of my

death for any civil or criminal purposes, nor shall it be considered unprofessional conduct or as

lack of professional competence. Any person, entity, institution, or facility against whom criminal

or civil liability is asserted because of conduct authorized by this Health Care Power of Attorney

may interpose this document as a defense.

E. Reimbursement. My health care agent shall be entitled to reimbursement for all reasonable

expenses incurred as a result of carrying out any provision of this directive.

By signing here, I indicate that I am mentally alert and competent, fully informed as to the contents of this

document, and understand the full import of this grant of powers to my health care agent.

This the _______ day of _________________________, 20____.

___________________________(SEAL)

I hereby state that the principal, ________________________, being of sound mind, signed (or directed

another to sign on the principal's behalf) the foregoing Health Care Power of Attorney in my presence,

and that I am not related to the principal by blood or marriage, and I would not be entitled to any portion of

the estate of the principal under any existing will or codicil of the principal or as an heir under the Intestate

Succession Act, if the principal died on this date without a will. I also state that I am not the principal's

attending physician or mental health treatment provider who is (1) an employee of the principal's

attending physician or mental health treatment provider, (2) an employee of the health facility in which the

principal is a patient, or (3) an employee of a nursing home or any adult care home where the principal

resides. I further state that I do not have any claim against the principal or the estate of the principal.

Date: ___________________________ Witness: ___________________________

______________ COUNTY, ____________________ STATE

Sworn to (or affirmed) and subscribed before me this day by ___________________________________

(type/print name of signer)

____________________________________

(type/print name of witness)

____________________________________

(type/print name of witness)

Date _____________________ ______________________________________

Signature of Notary Public

(Official Seal)

___________________________, Notary Public

Printed or typed name

My commission expires: __________________

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