Fillable Printable Living Will and Durable Power of Attorney for Health Care - Idaho

Living Will and Durable Power of Attorney for Health Care - Idaho

LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Date of Directive:

Name of person executing Directive:

Address of person executing Directive:

A Living Will

A Directive to Withhold or to Provide Treatment

1. I willfully and voluntarily make known my desire that my life shall not be

prolonged artificially under the circumstances set forth below. This Directive

shall be effective only if I am unable to communicate my instructions and:

a. I have an incurable or irreversible injury, disease, illness or condition, and

a medical doctor who has examined me has certified:

1. That such injury, disease, illness or condition is terminal; and

2. That the application of artificial life-sustaining procedures would

serve only to prolong artificially my life; and

3. That my death is imminent, whether or not artificial life-sustaining

procedures are utilized.

b. I have been diagnosed as being in a persistent vegetative state.

In such event, I direct that the following marked expression of my intent be followed and

that I receive any medical treatment or care that may be required to keep me free of

pain or distress.

Check one

box and initial the line after such box:



I direct that all medical treatment, care, and procedures necessary

to restore my health and sustain my life be provided to me. Nutrition and

hydration, whether artificial or non-artificial, shall not be withheld or withdrawn

from me if I would likely die primarily from malnutrition or dehydration rather than

from my injury, disease, illness or condition.



I direct that all medical treatment, care and procedures, including

artificial life-sustaining procedures, be withheld or withdrawn, except that

nutrition and hydration, whether artificial or non-artificial shall not be withheld or

withdrawn from me if, as a result, I would likely die primarily from malnutrition or

dehydration rather than from my injury, disease, illness or condition, as follows:

(If none of the following boxes are checked and initialed, then both nutrition and

hydration, of any nature, whether artificial or non-artificial, shall be administered.)

Check one box and init ial the line after such box:

 A. Only hydration of any nature, whether artificial or non-

artificial, shall be administered.

 B. Only nutrition, of any nature, whether artificial or non-

artificial, shall be administered.

 C. Both nutrition and hydration, of any nature, whether artificial

or non-artificial shall be administered.



I direct that all medical treatment, care and procedures be withheld

or withdrawn, including withdrawal of the administration of artificial nutrition and

hydration.

2. If I have been diagnosed as pregnant, this Directive shall have no force during

the course of my pregnancy.

3. I understand the full importance of this Directive and am mentally competent to

make this Directive. No participant in the making of this Directive or in its being

carried into effect shall be held responsible in any way for complying with my

directions.

4. Check one

box and initial the line after such box:

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

I have discussed these decisions with my physician and have also

completed a Physician Orders for Scope of Treatment (POST) form that contains

directions that may be more spec ific than, but are compatible with, this Directive.

I hereby approve of those orders and incorporate them herein as if fully set forth.



I have not completed a Physician Orders for Scope of Treatment

(POST) form. If a POST form is later signed by my physician, then this living will

shall be deemed modified to be compatible with the terms of the POST form.

A Durable Power of Attorney for Health Care

1. DESIGNATION OF HEALTH CARE AGENT

None of the following may be designated as your agent:

(1) your treating health care provider;

(2) a non-relative employee of your treating health care provider;

(3) an operator of a community care facility; or

(4) a non-relative employee of an operator of a community care facility.

If the agent or an alternate agent designated in this Directive is my spouse, and our

marriage is thereafter dissolved, such designation shall be thereupon revoked.

I do hereby designate and appoint the following individual as my attorney in fact (agent)

to make health care decisions for me as authorized in this Directive.

(Insert name, address and telephone number of one individual only as your agent to

make health care decisions for you.)

Name of Health Care Agent:

Address of Health Care Agent:

Telephone Number of Health Care Agent:

For the purposes of this Directive, "health care decision" means consent, refusal of

consent, or withdrawal of consent to any care, treatment, service, or procedure to

maintain, diagnose or treat an individual's physical condition.

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2. CREATION OF DURABLE PO WER OF ATTORNEY FOR HEALTH CARE

By this portion of this Directive, I create a durable power of attorney for health care.

This power of attorney shall not be affected by my subsequent incapacity. This power

shall be effective only when I am unable to communicate rationally.

3. GENERAL STATEMENT OF AUTHORITY GRANTED

I hereby grant to my agent full power and authority to make health care decisions for me

to the same extent that I could make such decisions for myself if I had the capacity to do

so. In exercising this authority, my agent shall make health care decisions that are

consistent with my desires as stated in this Directive or otherwise made known to my

agent including, but not limited to, my desires concerning obtaining or refusing or

withdrawing artificial life-sustaining care, treatment, services and procedures, including

such desires set forth in a living will, Physician Orders for Scope of Treatment (POST)

form, or similar document executed by me, if any.

(If you want to limit the authority of your agent to make health care decisions for you,

you can state the limitations in paragraph 4, "Statement of Desires, Special Provisions,

and Limitations", below. You can indicate your desires by including a statement of your

desires in the same paragraph.)

4. STATEMENT OF DESIRES, SP ECIAL PROVISIONS, AND LIMITATIONS

(Your agent must make health care decisions that are consistent with your known

desires. You can, but are not required to, state your desires in the space provided

below. You should consider whether you want to include a statement of your desires

concerning artificial life-sustaining care, treatment, services and procedures. You can

also include a statement of your desires concerning ot her matters relating to your health

care, including a list of one or more persons whom you designate to be able to receive

medical information about you and/or to be allowed to visit you in a medical institution.

You can also make your desires known to your agent by discussing your desires with

your agent or by some other means. If there are any types of treatment that you do not

want to be used, you should state them in the space below. If you want to limit in any

other way the authority given your agent by this Directive, you should state the limits in

the space below. If you do not state any limits, your agent will have broad powers to

make health care decisions for you, except to the extent that there are limits provided by

law.)

In exercising the authority under this durable power of attorney for health care, my

agent shall act consistently with my desires as stated below and is subject to the special

provisions and limitations stated in my Phys ician Order s for Scope of Treatment (POST)

form, a living will, or similar document executed by me, if any. Additional statement of

desires, special provisions, and limitations:

(You may attach additional pages or documents if you need more space to complete

your statement.)

5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY

PHYSICAL OR MENTAL HEALT H

A. General Grant of Power and Authority

Subject to any limitations in this Directive, my agent has the power and

authority to do all of the following:

(1) Request, review and receive any information, verbal or written,

regarding my physical or mental health including, but not limited to,

medical and hospital records;

(2) Execute on my behalf any releases or other documents that may be

required in order to obtain this information;

(3) Consent to the disclosure of this information; and

(4) Consent to the donation of any of my organs for medical purposes.

(If you want to limit the authority of your agent to receive and disclose information

relating to your health, you must state the limitations in paragraph 4, "Statement of

Desires, Special Provisions, and Limitations", above.)

B. HIPAA Release Author ity

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My agent shall be treated as I would be with respect to my rights regarding the

use and disclosure of my individually identifiable health information or other

medical records. This release authority applies to any information governed by

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

U.S.C. 1320d and 45 CFR 160 through164. I authorize any physician, health

care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or

other covered health care provider, any insurance company, and the Medical

Information Bureau, Inc. or other health care clearinghouse that has provided

treatment or services to me, or that has paid for or is seeking payment from me

for such services, to give, disclose and release to my agent, without restriction,

all of my individually identifiable health information and medical records regarding

any past, present or future medical or mental health condition, including all

information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases,

mental illness, and drug or alcohol abuse. The authority given my agent shall

supersede any other agreement that I may have made with my health care

providers to restrict access to or disclosure of my individually identifiable health

information. The authority given my agent has no expiration date and shall

expire only in the event that I revoke the authority in writing and deliver it to my

health care provider.

6. SIGNING DOCUMENTS, WAIVERS, AND RELEASES

Where necessary to implement the health care decisions that my agent is authorized by

this Directive to make, my agent has the power and authority to execute on my behalf

all of the following:

(a) Documents titled, or purporting to be, a "Refusal to Permit Treatment"

and/or a "Leaving Hospital Against Medical Advice"; and

(b) Any necessary waiver or release from liability required by a hospital or

physician.

7. DESIGNATION OF ALTERNATE AGENTS

(You are not required to designate any alternate agents but you may do so. Any

alternate agent you designate will be able to make the same health care decisions as

the agent you designated in paragraph 1 above, in the event that agent is unable or

ineligible to act as your agent. If an alternate agent you designat e is your spouse, he or

she becomes ineligible to act as your agent if your marriage is thereafter dissolved.)

If the person designated as my agent in paragraph 1 is not available or becomes

ineligible to act as my agent to make a health care decision for me or loses the mental

capacity to make health care decisions for me, or if I revoke that person's appointment

or authority to act as my agent to make health care decisions for me, then I designate

and appoint the following persons to serve as my agent to make health care decisions

for me as authorized in this Directive, such persons to serve in the order listed below:

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A. First Alternate Agent

Name:

Address:

Telephone Number:

B. Second Alternate Agent

Name:

Address:

Telephone Number:

C. Third Alternate Agent

Name:

Address:

Telephone Number:

8. PRIOR DESIGNATIONS REVOKED

I revoke any prior durable power of attorney for health care.

DATE AND SIGNATURE OF PRINCIPAL

(You must date and sign this Living Will and Durable Power of Attorney for Health

Care.)

I sign my name to this Statutory Form Living Will and Durable Power of Attorney for

Health Care on the date set forth at the beginning of this Form at:

(Signature) (City, State)