Fillable Printable North Carolina Health Care Power of Attorney Form

North Carolina Health Care Power of Attorney Form

SOUTH CAROLINA HEALTH CARE POWER OF

ATTORNEY

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 MAY 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 OTHER 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 ATTORNE Y 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.

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D. A BENEFICIARY OF A LIFE INSURANCE POLICY ON YOUR LIFE.

E. THE PERSONS NAMED IN THE HEALTH CARE POWER OF ATTORNEY 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, PROVIDER, 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 DISCUSS 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.

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SOUTH CAROLINA HEALTH CARE POWER OF

ATTORNEY

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 gua rdian, Probate Court, or surrogate make those decisions in accordance with my

directions 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 lim ited to, (i) diagnostic, treatment,

other health care, and related insurance and financial records and information associated with any past,

present, or future physical or mental 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 such health care agent(s) and/or al ternate health care

agent(s) may have requested. Without lim iting the generality of the foregoing, this release authority

applies to all health information and medical records governed by the Health Information Portability and

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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 term inate onl y 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 decisions 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 attemp t 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 in terpret 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 m edical 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 b e given effect in any situation to which they are applic able. My agent will have

authority to make decisions concerning my health care only in situations to which the Declaration does

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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 possib le, 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 R EGARDING TUBE FE EDING

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.

within the standards of accepted medical practice, without regard to m y 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 STA TEMENTS IN ITEM 8, YOUR AGENT WILL NOT

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HAVE AUTHORITY T O DIREC T THAT NUT RI TION 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 AGE NT.

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, marriage, 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:_________________________________________________________________________

________________________________________________________________________________

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(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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