§ 23-4.10-2 - Statutory form of durable power of attorney.
SECTION 23-4.10-2
§ 23-4.10-2 Statutory form of durablepower of attorney. – The statutory form of durable power of attorney is as follows:
STATUTORY FORM DURABLE POWER OF ATTORNEY FOR HEALTHCARE
WARNING TO PERSON EXECUTING THIS DOCUMENT
This is an important legal document which is authorized bythe general laws of this state. Before executing this document, you should knowthese important facts:
You must be at least eighteen (18) years of age and aresident of the state for this document to be legally valid and binding.
This document gives the person you designate as your agent(the attorney in fact) the power to make health care decisions for you. Youragent must act consistently with your desires as stated in this document orotherwise made known.
Except as you otherwise specify in this document, thisdocument gives your agent the power to consent to your doctor not givingtreatment or stopping treatment necessary to keep you alive.
Notwithstanding this document, you have the right to makemedical and other health care decisions for yourself so long as you can giveinformed consent with respect to the particular decision. In addition, notreatment may be given to you over your objection at the time, and health carenecessary to keep you alive may not be stopped or withheld if you object at thetime.
This document gives your agent authority to consent, torefuse to consent, or to withdraw consent to any care, treatment, service, orprocedure to maintain, diagnose, or treat a physical or mental condition. Thispower is subject to any statement of your desires and any limitation that youinclude in this document. You may state in this document any types of treatmentthat you do not desire. In addition, a court can take away the power of youragent to make health care decisions for you if your agent:
(1) Authorizes anything that is illegal,
(2) Acts contrary to your known desires, or
(3) Where your desires are not known, does anything that isclearly contrary to your best interests.
Unless you specify a specific period, this power will existuntil you revoke it. Your agent's power and authority ceases upon your deathexcept to inform your family or next of kin of your desire, if any, to be anorgan and tissue owner.
You have the right to revoke the authority of your agent bynotifying your agent or your treating doctor, hospital, or other health careprovider orally or in writing of the revocation.
Your agent has the right to examine your medical records andto consent to their disclosure unless you limit this right in this document.
This document revokes any prior durable power of attorney forhealth care.
You should carefully read and follow the witnessing proceduredescribed at the end of this form. This document will not be valid unless youcomply with the witnessing procedure.
If there is anything in this document that you do notunderstand, you should ask a lawyer to explain it to you.
Your agent may need this document immediately in case of anemergency that requires a decision concerning your health care. Either keepthis document where it is immediately available to your agent and alternateagents or give each of them an executed copy of this document. You may alsowant to give your doctor an executed copy of this document.
(1) DESIGNATION OF HEALTH CARE AGENT. I,
(insert your name andaddress)
do hereby designate and appoint:
(insert name, address, and telephone number of one individualonly as your agent to make health care decisions for you. None of the followingmay be designated as your agent: (1) your treating health care provider, (2) anonrelative employee of your treating health care provider, (3) an operator ofa community care facility, or (4) a nonrelative employee of an operator of acommunity care facility.) as my attorney in fact (agent) to make health caredecisions for me as authorized in this document. For the purposes of thisdocument, "health care decision" means consent, refusal of consent, orwithdrawal of consent to any care, treatment, service, or procedure tomaintain, diagnose, or treat an individual's physical or mental condition.
(2) CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. Bythis document I intend to create a durable power of attorney for health care.
(3) GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to anylimitations in this document, I hereby grant to my agent full power andauthority to make health care decisions for me to the same extent that I couldmake such decisions for myself if I had the capacity to do so. In exercisingthis authority, my agent shall make health care decisions that are consistentwith my desires as stated in this document or otherwise made known to my agent,including, but not limited to, my desires concerning obtaining or refusing orwithdrawing life-prolonging care, treatment, services, and procedures andinforming my family or next of kin of my desire, if any, to be an organ ortissue donor.
(If you want to limit the authority of your agent to makehealth care decisions for you, you can state the limitations in paragraph (4)("Statement of Desires, Special Provisions, and Limitations") below. You canindicate your desires by including a statement of your desires in the sameparagraph.)
(4) STATEMENT OF DESIRES, SPECIAL PROVISIONS, ANDLIMITATIONS. (Your agent must make health care decisions that are consistentwith your known desires. You can, but are not required to, state your desiresin the space provided below. You should consider whether you want to include astatement of your desires concerning life-prolonging care, treatment, services,and procedures. You can also include a statement of your desires concerningother matters relating to your health care. You can also make your desiresknown to your agent by discussing your desires with your agent or by some othermeans. If there are any types of treatment that you do not want to be used, youshould state them in the space below. If you want to limit in any other way theauthority given your agent by this document, you should state the limits in thespace below. If you do not state any limits, your agent will have broad powersto make health care decisions for you, except to the extent that there arelimits provided by law.)
In exercising the authority under this durable power ofattorney for health care, my agent shall act consistently with my desires asstated below and is subject to the special provisions and limitations statedbelow:
(a) Statement of desires concerning life-prolonging care,treatment, services, and procedures:
(b) Additional statement of desires, special provisions, andlimitations regarding health care decisions:
(c) Statement of desire regarding organ and tissue donation:
Initial if applicable:
[ ] In the event of my death, I request that myagent inform my family/next of kin of my desire to be an organ and tissuedonor, if possible.
(You may attach additional pages if you need more space tocomplete your statement. If you attach additional pages, you must date and signEACH of the additional pages at the same time you date and sign this document.)
(5) INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MYPHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, myagent has the power and authority to do all of the following:
(a) Request, review, and receive any information, verbal orwritten, regarding my physical or mental health, including, but not limited to,medical and hospital records.
(b) Execute on my behalf any releases or other documents thatmay be required in order to obtain this information.
(c) Consent to the disclosure of this information.
(If you want to limit the authority of your agent to receiveand disclose information relating to your health, you must state thelimitations in paragraph (4) ("Statement of desires, special provisions, andlimitations") above.)
(6) SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessaryto implement the health care decisions that my agent is authorized by thisdocument to make, my agent has the power and authority to execute on my behalfall of the following:
(a) Documents titled or purporting to be a "Refusal to PermitTreatment" and "Leaving Hospital Against Medical Advice."
(b) Any necessary waiver or release from liability requiredby a hospital or physician.
(7) DURATION. (Unless you specify a shorter period in thespace below, this power of attorney will exist until it is revoked.)
This durable power of attorney for health care expires on
(Fill in this space ONLY if you want the authority of youragent to end on a specific date.)
(8) DESIGNATION OF ALTERNATE AGENTS. (You are not required todesignate any alternate agents but you may do so. Any alternate agent youdesignate will be able to make the same health care decisions as the agent youdesignated in paragraph (1), above, in the event that agent is unable orineligible to act as your agent. If the agent you designated is your spouse, heor she becomes ineligible to act as your agent if your marriage is dissolved.)
If the person designated as my agent in paragraph (1) is notavailable or becomes ineligible to act as my agent to make a health caredecision for me or loses the mental capacity to make health care decisions forme, or if I revoke that person's appointment or authority to act as my agent tomake health care decisions for me, then I designate and appoint the followingpersons to serve as my agent to make health care decisions for me as authorizedin this document, such persons to serve in the order listed below:
(A) First Alternate Agent:
(Insert name, address, and telephone number of firstalternate agent.)
(B) Second Alternate Agent:
(Insert name, address, and telephone number of secondalternate agent.)
(9) PRIOR DESIGNATIONS REVOKED. I revoke any prior durablepower of attorney for health care.
DATE AND SIGNATURE OF PRINCIPAL
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this Statutory Form Durable Power ofAttorney for Health Care on ]]]]]]]]]]]]]] at
(Date) (City)
]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]
(State) ]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]
(You sign here)
(THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNEDBY ONE NOTARY PUBLIC OR TWO (2) QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOUSIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGESTO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAMETIME YOU DATE AND SIGN THIS POWER OF ATTORNEY.)
STATEMENT OF WITNESSES
(This document must be witnessed by two (2) qualified adultwitnesses or one (1) notary public. None of the following may be used as awitness:
(1) A person you designate as your agent or alternate agent,
(2) A health care provider,
(3) An employee of a health care provider,
(4) The operator of a community care facility,
(5) An employee of an operator of a community care facility.
I declare under penalty of perjury that the person who signedor acknowledged this document is personally known to me to be the principal,that the principal signed or acknowledged this durable power of attorney in mypresence, that the principal appears to be of sound mind and under no duress,fraud, or undue influence, that I am not the person appointed as attorney infact by this document, and that I am not a health care provider, an employee ofa health care provider, the operator of a community care facility, nor anemployee of an operator of a community care facility.
Option 1 – Two (2) Qualified Witnesses:
Signature: ]]]]]]]]]]]]]]]] Residence Address:
Print Name: ]]]]]]]]]]]]]]
Date: ]]]]]]]]]]]]]]]]]]]]]]]]
Signature: ]]]]]]]]]]]]]]]] Residence Address:
Print Name: ]]]]]]]]]]]]]]
Date: ]]]]]]]]]]]]]]]]]]]]]]]]
Option 2 – One Notary Public
Signature: ]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]] , NotaryPublic
Print Name: ]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]
Date: ]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]
My commission expires on: ]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]
(AT LEAST ONE OF THE ABOVE WITNESSES OR THE NOTARY PUBLICMUST ALSO SIGN THE FOLLOWING DECLARATION.)
I further declare under penalty of perjury that I am notrelated to the principal by blood, marriage, or adoption, and, to the best ofmy knowledge, I am not entitled to any part of the estate of the principal uponthe death of the principal under a will now existing or by operation of law.
Signature:
Print Name: