| |
SECTION
1
At the top of the form, print your full name and
address. Print the name, address, and phone number of the person you
choose as your Health Care Agent. (Optional: If you think your Agent
might not be available at any future time, you may name a second person
as an Alternate Agent. Your Alternate Agent will be called if your Agent
is unwilling or unable to serve.)
SECTION
2
Setting limits on your Agent's authority might
make it difficult for your Agent to act for you in an unexpected situation.
If you want your Agent to have full authority to act for you, leave
the limitations space blank. However, if you want to limit the kinds
of decisions you would want your Agent or Alternate Agent to make for
you, include them in the blank.
SECTION
3
BEFORE you sign, be sure you have two adults present
who can witness you signing the document. The only people who cannot
serve as witnesses are your Agent and Alternate Agent. Then sign the
document yourself. (Or, if you are physically unable, have someone other
than either witness sign your name at your direction. The person who
signs your name for you should put his/her own name and address in the
spaces provided.)
SECTION
4
Have your witnesses fill in the date, sign their
names and print their names and addresses.
SECTION
5
OPTIONAL: On the back of the form are statements
to be signed by your Agent and any Alternate Agent. This is not required
by law, but is recommended to ensure that you have talked with the person
or persons who may have to make important decisions about your care
and that each of them realizes the importance of the task they may have
to do.
Who
should have the original and copies?
After
you have filled in the form, remove this information page and make at
least four photocopies of the form. Keep the original yourself where
it can be found easily (not in your safe deposit box). Give copies to
your doctor and/or health plan to put into your medical record. Give
copies to your Agent and any Alternate Agent. You can give additional
copies to family members, your clergy and/or lawyer, and other people
who may be involved in your health care decision making.
How
can I revoke or cancel the document?
Your
Health Care Proxy is revoked when any of the following four things happens:
- You
sign another Health Care Proxy later on.
- You
legally separate from or divorce your spouse who is named in the Proxy
as your Agent.
- You
notify your Agent, your doctor, or other health care provider, orally
or in writing, that you want to revoke your Health Care Proxy.
- You
do anything else that clearly shows you want to revoke the Proxy,
for example, tearing up or destroying the Proxy, crossing it out,
telling other people, etc
|