|
WILLIAM DONALD SCHAEFER, Governor
S.B. 664
1. A. REQUEST, RECEIVE, AND REVIEW ANY INFORMATION,
ORAL OR WRITTEN, REGARDING MY PHYSICAL OR MENTAL HEALTH, INCLUDING,
BUT NOT LIMITED TO, MEDICAL AND HOSPITAL RECORDS, AND CONSENT TO
DISCLOSURE OF THIS INFORMATION;
2. B. EMPLOY AND DISCHARGE MY HEALTH CARE PROVIDERS;
3. C. AUTHORIZE MY ADMISSION TO OR DISCHARGE FROM
(INCLUDING TRANSFER TO ANOTHER FACILITY) ANY HOSPITAL, HOSPICE, NURSING
HOME, ADULT HOME, OR OTHER MEDICAL CARE FACILITY; AND
4. D. CONSENT TO OR REFUSE THE PROVISION, WITHHOLDING,
OR WITHDRAWAL OF ANY TYPE OF HEALTH CARE, INCLUDING, IN APPROPRIATE
CIRCUMSTANCES, LIFE PROLONGING LIFE-SUSTAINING PROCEDURES.
(3) THE AUTHORITY OF MY AGENT IS SUBJECT TO THE FOLLOWING
PROVISIONS AND LIMITATIONS:
(4) MY AGENT'S AUTHORITY BECOMES OPERATIVE (INITIAL THE
OPTION THAT APPLIES):
[ ] WHEN MY ATTENDING PHYSICIAN AND A SECOND PHYSICIAN
DETERMINE THAT I AM INCAPABLE OF MAKING AN INFORMED DECISION
REGARDING MY HEALTH CARE; OR .
[ ] WHEN THIS DOCUMENT IS SIGNED.
(5) MY AGENT IS TO MAKE HEALTH CARE DECISIONS FOR ME BASED ON
ANY THE HEALTH CARE INSTRUCTIONS I GIVE IN THIS DOCUMENT AND ON MY
WISHES AS OTHERWISE KNOWN TO MY AGENT. IF MY WISHES ARE UNKNOWN OR
UNCLEAR. MY AGENT IS TO MAKE HEALTH CARE DECISIONS FOR ME IN
ACCORDANCE WITH MY BEST INTERESTS INTEREST, TO BE DETERMINED BY MY
AGENT IN LIGHT OF MY PERSONAL VALUES AS OTHERWISE KNOWN TO MY AGENT
ON THE BASIS OF AN EVALUATION OF THE BENEFITS AND THE BURDENS THAT
AFTER CONSIDERING THE BENEFITS, BURDENS, AND RISKS THAT MIGHT RESULT FROM
A GIVEN TREATMENT OR COURSE OF TREATMENT, OR FROM THE WITHHOLDING OR
WITHDRAWAL OF A TREATMENT OR COURSE OF TREATMENT.
(6) MY AGENT SHALL NOT BE LIABLE FOR THE COSTS OF CARE BASED
SOLELY ON THIS AUTHORIZATION.
BY SIGNING BELOW, I INDICATE THAT I AM EMOTIONALLY AND MENTALLY
COMPETENT TO MAKE THIS APPOINTMENT OF A HEALTH CARE AGENT AND THAT I
UNDERSTAND ITS PURPOSE AND EFFECT.
(DATE) (SIGNATURE OF DECLARANT)
- 3307 -
|
