Declaration of a Durable Power of Attorney for Health Care Only

1. Declaration.

A. Life Sustaining Procedures. Declaration made on this date, _________, I, ________ (“Declarant”), being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition or a permanently unconscious condition by two (2) physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized, or that I will remain in a permanently unconscious condition, and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide me with comfortable care.

B. Hydration and Nutrition. I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial nutrition and hydration. In carrying out any instruction I have given under this section, I authorize that artificial nutrition and hydration BE STARTED, or if started, BE CONTINUED.

C. Pregnancy. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy. However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point. If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this Declaration shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

2. Declaration of Health care Agent. I, the Declarant, hereby appoint: _______________ (“Agent”) as my Agent to make any and all health care decisions for me, except to the extent I state otherwise in this document or as prohibited by law. My agent must act consistently with my desires as stated in this document or otherwise made known. This Durable Power of Attorney for Health Care shall take effect in the event I become unable to make my own health care decisions.

3. Statement of Desires, Special Provisions, and Limitations regarding Health Care Decisions and Options. I give my Agent power to act in these specified circumstances: If I become permanently incompetent to make health care decisions, and if I am also suffering from a terminal illness, I authorize my Agent to direct that life-sustaining treatment be discontinued. Whether terminally ill or not, if I become permanently unconscious I authorize my Agent to direct that life-sustaining treatment be discontinued. I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial feeding (artificial nutrition and hydration). In carrying out any instructions I have given in this power of attorney, I authorize my Agent to direct that artificial nutrition and hydration not to be started or, if started, be discontinued.

4. Designation of an Alternate Agent. In the event the person I appoint above is unable, unwilling or unavailable, or ineligible to act as my Health Care Agent, I hereby appoint the following persons as Alternate Agent:

First Alternate Agent

Agent Name:
Address:
Phone: Home: Work:

Second Alternate Agent

Agent Name:
Address:
Phone: Home: Work:

5. Other Provisions. I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this document. I have read and understand the information contained in the disclosure statement. I understand the full import of this Declaration and Durable Power of Attorney for Health Care and I am emotionally and mentally competent to make this Declaration and Durable Power of Attorney for Health Care.

6. Notices.

Any notice required by this Agreement or given in connection with it, shall be in writing and shall be given to the appropriate party by personal delivery or a recognized over night delivery service such as FedEx.

If to the Declarant: _____________________________________________________.

If to My Physician: ___________________________________________________.

7. No Waiver.

The waiver or failure of either party to exercise in any respect any right provided in this Agreement shall not be deemed a waiver of any other right or remedy to which the party may be entitled.

8. Entirety of Agreement.

The terms and conditions set forth herein constitute the entire agreement between the parties and supersede any communications or previous agreements with respect to the subject matter of this Agreement. There are no written or oral understandings directly or indirectly related to this Agreement that are not set forth herein. No change can be made to this Agreement other than in writing and signed by both parties.

9. Governing Law.

This Agreement shall be construed and enforced according to the laws of the State of ____________________ and any dispute under this Agreement must be brought in this venue and no other.

10. Headings in this Agreement

The headings in this Agreement are for convenience only, confirm no rights or obligations in either party, and do not alter any terms of this Agreement.

11. Severability.

If any term of this Agreement is held by a court of competent jurisdiction to be invalid or unenforceable, then this Agreement, including all of the remaining terms, will remain in full force and effect as if such invalid or unenforceable term had never been included.

In Witness whereof, the parties have executed this Agreement as of the date first written above.

_________________________ _______________________
Declarant My Physician

___________________
Date

We, the following witnesses, being duly sworn, each declare to the notary public or justice of the peace or other official signing below as follows:

1. Declarant affirmed that he or she is aware of the nature of the document and signed the instrument as a free and voluntary act for the purposes expressed, or expressly directed another to sign for him or her.

2. Each witness signed at the request of Declarant, in his or her presence, and in the presence of the other witness.

3. To the best of my knowledge, at the time of the signing, Declarant was at least 18 years of age, and was of sane and sound mind and under no constraint, duress, or undue influence.

4. Neither of the undersigned witnesses is (i) Declarant’s spouse, or (ii) Declarant’s attending physician, or person acting under the direction or control of the attending physician or any other person who has a claim against Declarant’s estate.

_________________
Witness Signature:

Name:
Address:

_________________
Witness Signature:

Name:
Address:

State of New Hampshire
County of

The foregoing instrument was acknowledged before me this Date: ________________.

______________________________
Notary Public or Justice of the Peace
My Commission Expires: _____________.

Copy List: Must include Physician; list them here: _____________________________.

Durable Power of Attorney for Health Care
Review List

This review list is provided to inform you about the document in question and assist you in its preparation. This is literally a “life and death” issue for you. Treat it seriously accordingly. You are turning your fate over to others, if you elect to sign it.

Except to the extent you state otherwise, this document gives the person you name as your Agent the authority to make any and all health care decisions for you when you are no longer capable of making them yourself. “Health care” means any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition. Your Agent, therefore, can have the power to make a broad range of health care decisions for you. Your Agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. Your Agent cannot consent or direct any of the following: commitment to a state institution, sterilization, or termination of treatment if you are pregnant and if the withdrawal of that treatment is deemed likely to terminate the pregnancy unless the failure to withhold the treatment will be physically harmful to you or prolong severe pain which cannot be alleviated by medication.

You may modify this document to indicate any treatment you do not desire, except as stated above, or treatment you want to be sure you receive. Your Agent’s authority will begin when your doctor certifies that you lack the capacity to make health care decisions. If for moral or religious reasons you do not wish to be treated by a doctor or examined by a doctor for the certification that you lack capacity, you must say so in the document and name a person to be able to certify your lack of capacity. That person may not be your Agent or Alternate Agent or any person ineligible to be your Agent.

If you want to give your Agent authority to withhold or withdraw the artificial providing of nutrition and fluids, your document must say so. Otherwise, your Agent will not be able to direct that. Under no conditions will your Agent be able to direct the withholding of food and drink for you to eat and drink normally.

Your Agent will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your Agent will have the same authority to make decisions about your health care as you would have had if made consistent with state law. If any of the above concerns you, don’t sign the document.

It is important that you discuss this document with your physician or other health care providers, as well as your lawyer, before you sign it to make sure that you understand the nature and range of decisions, which may be made, on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions.

The person you appoint as your Agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g., your physician, or an employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your Agent or as your health or residential care provider; the law does not permit a person to do both at the same time, for obvious reasons to protect your own interests.

You should consult the individual you would like to appoint in advance of signing this document so that they can affirmatively tell you the will be willing to undertake this possible life and death responsibility to act as your Health Care Agent. If they elect to not undertake this responsibility, thank them and find another prospect Agent and repeat the process until you find someone willing to act in this serious capacity on your behalf. Whatever you do, do not surprise someone with this responsibility. You should discuss this document with your agreed upon Agent and your physician and give each a signed copy. You should indicate on the document itself the people and institutions that will have signed copies. Your Agent will not be liable for health care decisions made in good faith on your behalf.

Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your Agent by informing him or her or your health care provider orally or in writing. If you get cold feet later, we have provided a revocation document in this Agreement. You may revoke the Agreement just to appoint another Agent, as circumstances dictate or your life or their life changes to make it inappropriate for them to act on your behalf.

We strongly recommend you appoint someone significantly younger than yourself as Agent, if you elect to sign this Agreement, to avoid, or at least increase the odds, of them predeceasing you or having serious health problems themselves which would prohibit them acting appropriately on your behalf.

This document may not be changed or modified. If you want to make changes in the document you must make an entirely new one. This includes, but is not limited to, appointing a new Agent as discussed above.

You should consider designating an Alternate Agent in the event that your Agent is unwilling, unable, unavailable, or ineligible to act as your Agent. Any Alternate Agent you designate will have the same authority to make health care decisions for you

This power of attorney will not be effective unless signed in the presence of 2 or more qualified witnesses. The following people may not act as witnesses: the nominated Agent or Alternate Agent; your spouse; any lawful heirs or beneficiaries named in your will or deed. Only one of the two witnesses may be your related in any way or capacity to your health or residential care provider for obvious conflict of interest reasons and your personal protection by the law and statute.

Many states require that each provision be separately initialed. Since this has become the standard, you should consider it an absolute requirement to initial each and every paragraph, or sign it in full, if you so prefer.

To be on the safe side, initial each and every page of this document to prevent page substitution and prevent that assertion being made in any court of law. In addition, indicate who is on the copy list so those copies are accounted for, and, if necessary, can be retrieved for purposes of authentication, modification, or revocation.

Reasons for an Update or Revocation

1. You change your mind for any reason whatsoever.

2. You learn you have a terminal condition after signing this health care directive. This will provide an opportunity to restate or change your wishes in light of your new health status.

3. Change or set limits on the medical care that is provided.

4. Respond to a changing medical technology.

5. Respond to a change in health care laws.

6. Respond to a change in health, including pregnancy.

7. Life circumstances suggest appointing a different Agent.

8. Many more. Do not be reluctant to modify this Agreement should you so desire.

We strongly recommend you speak to your lawyer and clergyman about these decisions to be sure you are comfortable with them. This is literally a “life and death” situation. It bears serious discussion with those you trust most.

Name Insurance Coverage In:
Plan #:
Family Name Covered Under Plan:
Individual Covered & Subject to This Letter:
Social Security Number of Individual:

To: Medical Office Manager

I am writing to request a copy of my medical records. Please send it to me at the address on this letterhead.

I was formerly a patient of Dr. __________. Enclosed is a signed Authorization to Release Medical Records. I am requesting the records for insurance-related reasons.

If there is a charge for copying the records, please submit a statement with the records and I will remit payment or charge it to my credit card number: ____________________ Expiration Date: _________; Under my name listed exactly as: __________________.

Thank you for your continued good service that I have received in the past.
Best regards,
____________
Writer

Enclosure: Authorization to Release Medical Records
Faxed and Mailed (Unless you can’t fax; if you cannot, then remove this notation).

Authorization to Release Medical Records, Cover Letter
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This is a benign request in the medical world. Therefore, be nice; clear; have your documents together for easy administration (the bane of all of these medical groups). At the end of the above letter, write a short handwritten note saying, “Thanks for your continued help; appreciate your fast response so I can get on with it.” This makes your request for speed less annoying and more personal at the same time. A double win.

The separate document for Authorization itself lends formality and precision to your approach. It is complete and suggests you know what you are doing, so they will want to get you off their hands more quickly than others that reach their in pile. Remember, in the medical world, the challenge is to get in their “A” pile that they attend to and stay out of their “B” pile that they do not! Amusing perhaps; but deadly accurate as a wise overall objective in the medical world. They have tons of paperwork to attend to; make sure you provide emotional (when possible), paperwork, and simplicity incentive for them to deal with you immediately.

Faxing and mailing it, as a backup, is the recommended approach. Delivers both immediacy and original signatures for them.

Some medical offices require you to fill out their own release forms. If so, we believe it more expeditious to just present them with yours, which may make them overlook their own bureaucratic tangle, and just release them. At a minimum, this approach won’t hurt; it will certainly let them know you have taken the request, and therefore “them,” seriously. Medical people like that. So you are ahead of the game giving them everything they need should they accept it. If they don’t, you can fill out their form and send it in virtually the same amount of time.

Related: Release of Medical Records

_________________ (“Patient”) of __________________________________(Address), with Social Security Number ___________________, hereby authorizes the release, disclose, and delivery of the medical information described below to: _______________
(Authorized Recipient).

Specific Authorization. I specifically authorize the release of all medical information relating to the above-named patient including but not limited to the following categories protected by state or federal law: (1) Substance abuse (drug or alcohol) treatment (2) Mental health treatment and (3) HIV-AIDS-related information, if such information is contained in the records. This request includes any reports, correspondence, test results, and any other information contained in the records, whether generated by the authorized provider or another entity.

I do not give permission for any other use or redisclosure of this information.

Yours very truly,

____________
Patient

Redisclosure. This release does not authorize redisclosure of medical information beyond the limits of this consent. The Recipient of this information is prohibited from using the information for other than the stated purpose, and from disclosing it to any other party without further authorization from me, the patient. The following written statement should accompany certain disclosures:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

The Patient specifically understands and agrees that the REDISCLOSURE requirements set out above will apply to these records.

Validity and Time Period. I understand that this authorization will automatically expire one year from the date of my signature, and that I may revoke this authorization by sending a written notice to the person or entity authorized to make the disclosure described above. I agree that any release which has been made prior to revocation and which was made in reliance upon this authorization shall not constitute a breach of my rights to confidentiality.

I authorize the release of information as indicated above.

____________________ Date: ________________
Patient

Authorization for Release of Medical Records
Review List

This review list is provided to inform you about the document in question and assist you in its preparation. Remember to include the cover letter and read the review list prior to doing so.

1. The Authorization must be signed and dated in two places by the patient or the patient’s authorized representative, such as a parent for a minor. The first signature specifies what medical records can and cannot be released. The second signature relates to the entire form.

2. Send two signed copies to the health care provider. They can keep one set and send you back the other.

3. If this release is for litigation purposes, your litigation lawyer should handle the matter directly with the Health Care Provider on your behalf.

Related: Release of Medical Records Cover Letter

I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct that my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.

Signed this ____________________ day of _______________

________________________________________________________________

Signature: __________________
City of residence: __________
County of residence: ________
State of residence: _________

The Declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence.

________________________________________________________________

Witness
Address:

________________________________________________________________

Witness
Address:

Declaration in Conformance with Missouri Statutes 459.015
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Missouri. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________. I, __________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, do hereby declare:
1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally,
2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
3. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy.
4. I have been diagnosed and notified at least 14 days ago as having a terminal condition by __________________, M.D. whose address is ___________, __________.

I understand that if I have not filed in the physicians name and address, it shall be presumed that I did not have a terminal condition when I made out this directive.
5. This directive shall have no force and effect five years from the date filled in above.
6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

_________________________________________________

The Declarant has been personally known to me and I believe him or her to be of sound mind.

Witness __________________________________________________

Witness __________________________________________________

Directive to Physicians as Provided by the California Health and Safety Code: Section 7187
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in California. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to be. To any individual who may become responsible for my health, welfare or affairs.

Death is as much a reality as birth, growth, maturity and old age — it is the one certainty of life. If the time comes when I, ________________, can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes while I am still of sound mind.

If the situation should arise in which I am in terminal state and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I do, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life.

This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that those to whom this will is addressed will regard themselves as morally bound by these provisions. If it is permissible under the laws of the jurisdiction in which I may be hospitalized I direct that the physicians supervising my care upon a terminal diagnosis to discontinue hydration (water) should the continuation of hydration be judged to result in unduly prolonging a natural death.

If it is permissible under the laws of the jurisdiction in which I may be hospitalized I direct that the physicians supervising my care upon a terminal diagnosis to discontinue feeding should the continuation of hydration be judged to result in unduly prolonging a natural death.

I herewith release any and all hospitals, physicians, and others both for myself and for my estate from any and all liability for complying with this declaration, to the fullest extent provided by law.
I herewith authorize my spouse, if any, or any relative who is related to me within the third degree to effectuate my transfer from any hospital or other health care facility in which I may be receiving care should that facility decline or refuse to effectuate the instructions given herein.

Signed:

_______________________________________________________________

City of residence: _______________
County of residence: _____________
State of residence: ______________
Social Security Number: __________

Date: _________________

________________________________________________________________
Witness

________________________________________________________________
Witness

STATE OF ________________________
COUNTY OF _______________________

This day personally appeared before me, the undersigned authority, a Notary Public in and for ______________ County, ___________________________State, ______________________________ _______________________________(Witnesses) who, being first being duly sworn, say that they are the subscribing witnesses to the declaration of ________________, the Declarant, signed, sealed and published and declared the same as and for his declaration, in the presence of both these affiants; and that these affiants, at the request of said Declarant, in the presence of each other, and in the presence of said Declarant, all present at the same time, signed their names as attesting witnesses to said declaration.

Affiants further say that this affidavit is made at the request of ________________, Declarant, and in his presence, and that ________________ at the time the declaration was executed, in the opinion of the affiants, of sound mind and memory, and over the age of eighteen years.
Taken, subscribed and sworn to before me by _________________ (witness) and ____________________________ (witness) this _______ day of ____________________________, 20_____.

My commission expires: __________________

___________________________________
Notary Public

Living Will
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in many states. It is a general format for those states without specific ones, though it will generally be enforced if done and properly witnessed, in most states. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION OF ______________________

This declaration is made this __________ day of __________ 20___________. I, _____________________________, being of sound mind, willfully and voluntarily make known my desires that my moment of death shall not be artificially postponed.

If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal condition by my attending physicians who has personally examined me, and has determined that my death is imminent except for death delaying procedures, I direct that such procedures which would serve only to prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide me with comfort care.

In the absence of my ability to give directions regarding the use of such death delaying procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

________________________________________

City of Residence: ________________
County of Residence: ______________
State of Residence: _______________

Date: __________________________________

Witness _________________________________________________

Witness _________________________________________________

Date: ___________________________________

Statutory Declaration in Conformance with Illinois Natural Death Act, IL. Stat. 110 ½ Paragraph 703
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Illinois. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

I, __________________, (“Declarant”), of ____________________________________
(Address), do hereby revoke any and all power and authority granted to my physician, health care provider, or health care agent in the past, but especially the previous Health Care Durable Power Attorney attached in Exhibit 1, and dated _________________, appointing ________________________ to act as my health care Agent. All such Durable Power of Attorney’s, including but not limited to the one named above, are hereby revoked and withdrawn and this document provides notice of such revocation.

______________________ ___________________________
Declarant My Physician

I acknowledge and declare I am not the Declarant’s spouse or heir at the time of witnessing this document, nor am I associated with any health care facility in which Declarant resides or uses in any manner whatsoever.

____________________________
Witness Signature:

Witness Name:
Witness Address:

____________________________
Witness Signature:

Witness Name:
Witness Address:

Names of institutions/individuals who have been provided a copy of this revocation: Should include all parties receiving prior Agreement and the signatory thereto, “My Physician.”

Revocation of Health Care Durable Power of Attorney
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. If in doubt, revoke your Health Care Durable Power of Attorney. Make sure that your Revocation accurately identifies the document(s) that you wish to revoke. The full title of each document you are revoking, as stated on the document, should be identified on the Revocation.

Because the attending physician or health care provider must receive notice of the Revocation, it is recommended that the Revocation be mailed by certified mail to the provider’s last known address. Alternatively, a copy of the Revocation may be hand-delivered to the provider, in which case the provider should sign the document acknowledging receipt of the Revocation. The latter is a better solution, all the way around. If Declarant is residing in any health care or other related facility, a copy of the Revocation should be place in his or her Medical file.

1. Make multiple copies so the original attending physician, “My physician,” has a copy as well as for your estate planning file and a separate copy for yourself.

2. Any new Health Care Durable Power of Attorney will supercede the Revocation. However, if you do take this step, you are advised to reference the former Revocation and include it as an exhibit to your new document. Do this to keep your records in order and make sure your directives are followed without document dispute.

I, ________________, desire to make aware that after mature reflection, and, being aware of the right under the law to decline life- sustaining treatment, that I wish, should I ever be unable to make decisions for myself concerning my medical treatment that I receive life sustaining treatment even after a terminal diagnosis, even if the life prolonging treatment will delay the natural process of dying.

I have previously made a “living will” or other document expressing a desire contrary to that specified herein, and by this document I herewith revoke the same.

Dated: _________________________________________

________________________________________________
Declarant

________________________________________________
Witness & Address

________________________________________________
Witness & Address

________________________________________________
Witness & Address

City of residence: _______________
County of residence: _____________
State of residence: ______________
Social Security Number: __________

Date: _________________

________________________________________________________________
Witness

________________________________________________________________
Witness

STATE OF ________________________
COUNTY OF _______________________

This day personally appeared before me, the undersigned authority, a Notary Public in and for ______________ County, ___________________________State, ______________________________ _______________________________(Witnesses) who, being first being duly sworn, say that they are the subscribing witnesses to the declaration of ________________, the Declarant, signed, sealed and published and declared the same as and for his declaration, in the presence of both these affiants; and that these affiants, at the request of said Declarant, in the presence of each other, and in the presence of said Declarant, all present at the same time, signed their names as attesting witnesses to said declaration.

Affiants further say that this affidavit is made at the request of ________________, Declarant, and in his presence, and that ________________ at the time the declaration was executed, in the opinion of the affiants, of sound mind and memory, and over the age of eighteen years.
Taken, subscribed and sworn to before me by _________________ (witness) and ____________________________ (witness) this _______ day of ____________________________, 20_____.

My commission expires: __________________

Revocation of Previous Living Will and Medical Care Restrictions
Review List

This review list is provided to inform you about this document in question and you in its preparation. Revocations are generally made because of a serious change in attitude. Therefore, you should be very careful to have your wishes implemented. Get three witnesses; have them notarized; get the documents in everyone’s hands that previously had one; and try to recover as many originals as you can, that you handed out previously, to avoid conflicting directions.

DIRECTIVE TO PHYSICIANS

Date __________________

I, _______________, being of sound mind, intentionally and voluntarily declare:
1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally,
2. It is my intention that this directive shall be honored by my family and attending physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
3. If I have been diagnosed as pregnant and that fact is known to my physician, this directive shall have no force or effect during the course of my pregnancy. I understand the full import of this directive and I am emotionally and mentally competent to execute it.

Signed _________________________________________________

STATE OF _______
COUNTY OF __________

Dated: _________________________

Then and there personally appeared the within named ________________________________ and __________________________, who, being duly sworn, depose and say: That they witnessed the execution of the within Directive to Physicians of the within named _______________, that said declarant subscribed said Directive to Physicians and declared the same to be his Directive to Physicians in their presence, that they thereafter subscribed the same as witnesses in the presence of said declarant and in the presence of each other and at the request of said declarant; that the said declarant at the time of the execution of said Directive
to Physicians appeared to them to be of full age and of sound mind and memory, and that they make this affidavit at the request of said declarant.

________________________________________
Witness
________________________________________
Witness

Subscribed to and sworn to before me this ________ day of _________, 20_____.

_____________________________________________
Notary Public

Directive to Physicians as Provided by Nevada Revised Statutes, Section 449.610
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Nevada. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.