Health Care Power Of Attorney Form - South Carolina (Page 4 of 7) in pdf

Accountability Act of 1996 (HIPAA), 42 USC 1320d and 45 CFR 160-164; is effective whether or not I

am mentally competent; has no expiration date; and shall terminate only in the event that I revoke the

authority in writing and deliver it to my health care provider.

4. AGENT'S POWERS

I grant to my agent full authority to make decisions for me regarding my health care. In exercising this

authority, my agent shall follow my desires as stated in this document or otherwise expressed by me or

known to my agent. In making any decision, my agent shall attempt to discuss the proposed decision

with me to determine my desires if I am able to communicate in any way. If my agent cannot determine

the choice I would want made, then my agent shall make a choice for me based upon what my agent

believes to be in my best interests. My agent's authority to interpret my desires is intended to be as broad

as possible, except for any limitations I may state below.

Accordingly, unless specifically limited by the provisions specified below, my agent is authorized as

follows:

To consent, refuse, or withdraw consent to any and all types of medical care, treatment, surgical

procedures, diagnostic procedures, medication, and the use of mechanical or other procedures that affect

any bodily function, including, but not limited to, artificial respiration, nutritional support and hydration,

and cardiopulmonary resuscitation;

To authorize, or refuse to authorize, any medication or procedure intended to relieve pain, even

though such use may lead to physical damage, addiction, or hasten the moment of, but not intentionally

cause, my death;

To authorize my admission to or discharge, even against medical advice, from any hospital,

nursing care facility, or similar facility or service;

To take any other action necessary to making, documenting, and assuring implementation of

decisions concerning my health care, including, but not limited to, granting any waiver or release from

liability required by any hospital, physician, nursing care provider, or other health care provider; signing

any documents relating to refusals of treatment or the leaving of a facility against medical advice, and

pursuing any legal action in my name, and at the expense of my estate to force compliance with my

wishes as determined by my agent, or to seek actual or punitive damages for the failure to comply.

The powers granted above do not include the following powers or are subject to the following

rules or limitations:

_____________________________________________________________________________

5. ORGAN DONATION (INITIAL ONLY ONE)

My agent may ____; may not ____ consent to the donation of all or any of my tissue or organs for

purposes of transplantation.

6. EFFECT ON DECLARATION OF A DESIRE FOR A NATURAL DEATH (LIVING WILL)

I understand that if I have a valid Declaration of a Desire for a Natural Death, the instructions contained

in the Declaration will be given effect in any situation to which they are applicable. My agent will have

authority to make decisions concerning my health care only in situations to which the Declaration does

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Health Care Power Of Attorney Form - South Carolina Page 4