Living Will Form

HEALTH CARE POWER OF ATTORNEY WITH MENTAL HEALTH AUTHORITY
It is important to choose someone to make healthcare decisions for you when you cannot. Tell the person (agent) you choose what you would want. The person you choose has the right to make any decision to ensure that your wishes are honored. If you DO NOT choose someone to make decisions for you, write NONE in the line for the agent’s name.

I,   First Name   Last Name   , as Principal, designate   1   , as my agent to act in all matters relating to my health care (including my mental health care) and including, without limitation, the power to give or refuse consent to all medical and surgical treatments, hospitalizations and related health care. This power of attorney is effective at the point when I am not longer able to communicate my health care wishes. My agent's decisions under this power of attorney, during any period when I am unable to make and/or communicate my health care decisions or when there is uncertainty as to whether I am dead or alive, are binding on my heirs, devisees and personal representatives.

My Agent Phone:   Area Code   Phone Number
My Agent Address:   Street Address   Address Line 2   City   State   Zip

Please check all that apply.
I specifically consent to giving my agent the power to admit me to an inpatient or partial psychiatric hospitalization program if ordered by my physician.   By initialing here, this Health Care Directive including Mental Health Care Power of Attorney may not be revoked if I am incapacitated.

If my agent is unwilling or unable to serve, I hereby appoint as my successor agent:
Successor Agent’s Name:   First Name   Last Name
Phone Number:   Area Code   Phone Number
Address:     Street Address   Address Line 2   City   State   Zip

I intend for my agent to receive any and all of my health records and information as if I were the one requesting such information. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1420D and 45 CFR 160-164.
Date
MonthDayYear
Date
Signature
Clear
On the date set forth above, I hereby state as follows:

The above named person is personally known to me, and I believe him/her to be of sound mind and to have voluntarily executed this document. I am at least 18 years old, not related to him/her by blood, marriage or adoption, and I am not an agent or successor agent named in this document. To my knowledge, I am not a beneficiary of his/her will or any codicil, and I have no claim against his/her estate. I am not directly involved in his/her health care.
Witness Name
First NameLast Name
Witness Phone Number
Please enter a valid phone number.
Witness Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Witness Signature
Clear
NOTARY ACKNOWLEDGMENT
On Date , I personally appeared before me the person signing, known by me to be the person who completed this document and acknowledged it as his/her free act and deed. IN WITNESS THEREOF, I have set my hand and affixed my official seal in the County of 2, State of 3, on the date written above.

Notary Public: 4
Should be Empty:

Living Will Form

First Section

Second Section

Third Section (End of life wishes)

HEALTH CARE POWER OF ATTORNEY WITH MENTAL HEALTH AUTHORITY

NOTARY ACKNOWLEDGMENT