Xi
This is the Living Will of
currently resident at care, or advance medical directives.
Wti,{,
I hereby revoke any previous living wills, personal directives, powers of attorney for health
1.
MyAgent:
I appoint as my Agent to make personal and health- and medical-care decisions on my
behalf when I no longer have the capacity to make such decisions
currently resident at For the purposes of this document, "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.
2.
tf
Alternate Agent:
is unwilling or unable to act as my Agent, then
I
appoint the first person on the following list who is able and willing to serve as my Alternate Agent:
of
of
of lf my spouse has been designated as an Agent or Alternate Agent above, and if after the
execution of this document, my spouse and I are legally separated or divorced, any rights and powers granted to my spouse by this document shall immediately terminate on such legal separation or divorce.
Any reference to Agent in this document shall include the meaning Alternate Agent
where such Alternate Agent is acting as provided in this document.
3.
Effective:
I
I recognize that a time may come when by reason of illness or mental incapacity
cannot participate in my health-care or medical-care decisions.
SELF-COU NSEL PRESS-LIVINGWILL (PAGEI of4)05
lf at any time I should be certified by two physicians who have personally examined me, one of whom is my attending physician, to be in a persistent vegetative state such
that I am unable to make or communicate my own decisions by speaking, by writing, or
by gesturing, this document will be in effect and the decision-making powers granted by this document will be granted to my Agent.
4.
PowerofAgent:
Subject to any limitations in this document, 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. ln exercising this authority, my
Agent shall make health-care decisions that are consistent with 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 or withdrawing life-prolonging care, treatment, services, and procedures.
5.
lnspection and Disclosure of Information:
Subject to any limitations in this document, my Agent has the power and authority to do all of the following:
A.
Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records.
B.
C. D.
Execute on my behalf any releases or other documents that may be required in order to obtain this information. Consent to the disclosure of this information. Consent to the donation of any of my organs for medical purposes.
6.
Signing Documents, Waivers, and Releases:
Where necessary to implement the health-care decisions that my Agent is authorized by
this document 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 "Refusalto Permit Treatment'and "Leaving Hospital Against Medical Advice."
B. Any
necessary waiver or release from liabili$ required by a hospital or physician.
7. Visiting
Rights:
I hereby request that all medical or care facilities in which I may be placed give to my
Agent primary visiting rights as well as the right to admit or exclude other visitors.
SELF-COU NSEL PRESS-L lvl NGWI LL (PAG
2of4)05
8.
Statement of Desires, Special Provisions, and Limitations:
ln exercising the authority under this document, my Agent shall act consistently with my desires as stated below:
SELF-COUNSEL PRESH-IV|NGW| LL (PAGE3of4)QS
9
I ,,
Signature:
of
being of sound mind, confirm that I understand the full import of this living will and the power that it gives to my Agent and further confirm that this document represents my Wishes. Signed: on
this_
day of.
,20
10. Witnessed:
I declare that the person who signed or acknowledged this document is personally
known to me (or proved to me on the basis of convincing evidence) to be the principal, that the principal signed or acknowledged this document in my presence, 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 Agent by this document, and that I am not a
health-care provider, an employee of a health-care provider, the operator of a community care facility, an employee of an operator of a community care facility, or a lawful heir or beneficiary named in a Will or deed executed by the principal.
Signature: Print name:
Date:
Residence address:
Signature: Print name:
Date:
Residence address:
SELF-COU NSEL PRESS-L|V|NGW! LL (PAGE4of4)05
