Item (1) Write the name, home address and telephone number of the
person you are selecting as your agent.
Item (2) If you want to appoint an alternate agent, write the name,
home address and telephone number of the person you are selecting as your
alternate agent.
Item (3) Your Health Care Proxy will remain valid indefinitely unless
you set an expiration date or condition for its expiration. This section is
optional and should be filled in only if you want your Health Care Proxy to
expire.
Item (4) If you have special instructions for your agent, write them
here. Also, if you wish to limit your agent's authority in any way, you may say
so here or discuss them with your health care agent. If you do not state any
limitations, your agent will be allowed to make all health care decisions that
you could have made, including the decision to consent to or refuse
life-sustaining treatment.
If you want to give your agent broad authority, you may do so right on the
form. Simply write:
I have discussed my wishes with my health care agent and
alternate and they know my wishes including those about artificial nutrition and
hydration.
If you wish to make more specific instructions, you could say:
If I become terminally ill, I do/don't want to receive the
following types of treatments....
If I am in a coma or have little conscious understanding,
with no hope of recovery, then I do/ don't want the following types of
treatments:....
If I have brain damage or a brain disease that makes me
unable to recognize people or speak and there is no hope that my condition will
improve, I do/don't want the following types of treatments:....
I have discussed with my agent my wishes about _______ and
I want my agent to make all decisions about these measures.
Examples of medical treatments about which you may wish to give your agent
special instructions are listed below. This is not a complete list:
- artificial respiration
- artificial nutrition and hydration (nourishment and water provided by
feeding tube)
- cardiopulmonary resuscitation (CPR)
- antipsychotic medication
- electric shock therapy
- antibiotics
- surgical procedures
- dialysis
- transplantation
- blood transfusions
- abortion
- sterilization
Item (5) You must date and sign this Health Care Proxy form. If you
are unable to sign yourself, you may direct someone else to sign in your
presence. Be sure to include your address.
Item (6) You may state wishes or instructions about organ and/or
tissue donation on this form. A health care agent cannot make a decision about
organ and/or tissue donation because the agent's authority ends upon your death.
The law does provide for certain individuals in order of priority to consent to
an organ and/or tissue donation on your behalf: your spouse, a son or daughter
18 years of age or older, either of your parents, a brother or sister 18 years
of age or older, a guardian appointed by a court prior to the donor's death, or
any other legally authorized person.
Item (7) Two witnesses 18 years of age or older must sign this Health
Care Proxy form. The person who is appointed your agent or alternate agent
cannot sign as a witness.
Download a Health Care Proxy
form today.