Durable Power Of Attorney For Health Care Form printable pdf download

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Notice to Person Executing This Document

This is an important legal document. Before executing this document you should know these facts:

This document gives the person you designate as your Health Care Agent the power to make MOST health care decisions

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for you if you lose the capability to make informed health care decisions for yourself. This power is effective only when

you lose the capacity to make informed health care decisions for yourself. As long as you have the capacity to make

informed health care decisions for yourself, you retain the right to make all medical and other health care decisions.

You may include specific limitations in this document on the authority of the Health Care Agent to make health care

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decisions for you.

Subject to any specific limitations you include in this document, if you do lose the capacity to make an informed deci-

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sion on a health care matter, the Health Care Agent GENERALLY will be authorized by this document to make health

care decisions for you to the same extent as you could make those decisions yourself, if you had the capacity to do so.

The authority of the Health Care Agent to make health care decisions for you GENERALLY will include the authority

to give informed consent, to refuse to give informed consent, or to withdraw informed consent to any care, treatment,

service, or procedure to maintain, diagnose, or treat a physical or mental condition. You can limit that right in this doc-

ument if you choose.

When exercising his or her authority to make health care decisions for you when deciding on your behalf, the Health

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Care Agent will have to act consistent with your wishes, or if they are unknown, in your best interest. You may make

your wishes known to the Health Care Agent by including them in this document or by making them known in

another manner.

When acting under this document the Health Care Agent GENERALLY will have the same rights that you have to

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receive information about proposed health care, to review health care records, and to consent to the disclosure of health

care records.

1. Creation of Durable Power of Attorney for Health Care

I intend to create a power of attorney (Health Care Agent) by appointing the person or persons designated herein to make

health care decisions for me to the same extent that I could make such decisions for myself if I was capable of doing so, as

recognized by RCW 11.94.010. This designation becomes effective when I cannot make health care decisions for myself

as determined by my attending physician or designee, such as if I am unconscious, or if I am otherwise temporarily or

permanently incapable of making health care decisions. The Health Care Agent’s power shall cease if and when I regain my

capacity to make health care decisions.

2. Designation of Health Care Agent and Alternate Agents

If my attending physician or his or her designee determines that I am not capable of giving informed consent to health

care, I ______________________________________________, designate and appoint:

Name ___________________________________________________________Address ____________________________________________

City _________________________________________ State ______________ZIp ____________phone ______________________________

as my attorney-in-fact (Health Care Agent) by granting him or her the Durable power of Attorney for Health Care recognized in RCW 11.94.010

and authorize her or him to consult with my physicians about the possibility of my regaining the capacity to make treatment decisions and to

accept, plan, stop, and refuse treatment on my behalf with the treating physicians and health personnel.

In the event that __________________________________________________is unable or unwilling to serve, I grant these powers to

Name ___________________________________________________________Address ____________________________________________

City _________________________________________ State ______________ZIp ____________phone ______________________________

In the event that both ______________________________________________and _______________________________________________

are unable or unwilling to serve, I grant these powers to

Name ___________________________________________________________Address ____________________________________________

City _________________________________________ State ______________ZIp ____________phone ______________________________

Durable Power Of Attorney For Health Care Form

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