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Alabama _________________________________________________________________ Date: ______________________________ -5- ______ Signature of Second Choice for Proxy: I, ________________________________________________________, am willing to serve as the health care proxy if the first choice cannot serve. Signature: _____________________________________________, am willing to serve as the health care proxy. Signature: _____________________________________________________________________ Date: ________________________________________________________ Signature: _____________________________________________________________________ Date: ______________________________ Section 6. Signature of Proxy I, _________________________________________ -4- Signature: _____________________________________________________________________ Dated: ______________________________ Name of second witness: _________________________titled to any part of his or her estate. I am at least 19 years of age and am not directly responsible for paying for his or her medical care. Name of first witness: __________________________________ because I believe this person to be of sound mind. I did not sign the person's signature, and I am not the health care proxy. I am not related to the person by blood, adoption, or marriage and not en___________________________________________ Date signed: ___________________________________________________________________ Section 5. Witnesses (two witnesses need to sign) I am witnessing this formr name: ___________________________________________________________________ The month, day, and year of your birth: _____________________________________________ Your signature: ______________________along with my wishes, with my health care proxy, if I have one, and with the following people: _____________________________________________________________________________ Section 4. My signature You of the baby. If the time comes for me to stop receiving life sustaining treatment or food and water through a tube or an IV, I direct that my doctor talk about the good and bad points of doing this, ey must see that I get to a doctor or hospital who will follow my directions. If I am pregnant, or if I become pregnant, the choices I have made on this form will not be followed until after the birthhat I have listed on this form. Section 3. The things listed on this form are what I want. I understand the following: If my doctor or hospital does not want to follow the directions I have listed, th form and to make any decisions about things I have not covered in the form. ________ I want my health care proxy to make the final decision, even though it could mean doing something different from wnly one of the following: -3- _______ I want my health care proxy to follow only the directions as listed on this form. ________ I want my health care proxy to follow my directions as listed on thisour initials by either "yes" or "no": I want my health care proxy to make decisions about whether to give me food and water through a tube or an IV. _________ Yes _________ No Place your initials by o City: ___________________________________ State: ___________________ Zip: _________ Day-time phone number: __________________ Night-time phone number: _________________ Instructions for Proxy Place y______________________________________ Relationship to me: _____________________________________________________________ Address: ________________________________________________________________________ Night-time phone number: _________________ If this person is not able, not willing, or not available to be my health care proxy, this is my next choice: Second choice for proxy: ___________________ress: ______________________________________________________________________ City: ___________________________________ State: ___________________ Zip: _________ Day-time phone number: ________________h this person about my wishes. First choice for proxy: ___________________________________________________________ Relationship to me: _____________________________________________________________ Addy one answer: _________ I do not want to name a health care proxy. (If you check this answer, go to Section 3) _________ I do want the person listed below to be my health care proxy. I have talked wit person is called a health care proxy. You do not have to name a health care proxy. The directions in this form will be followed even if you do not name a health care proxy. Place your initials by onleed someone to speak for me. This form can be used in the State of Alabama to name a person you would like to make medical or other decisions for you if you become too sick to speak for yourself. This________________________________________________________________ If you do not have other directions, place your initials here: ________ No, I do not have any other directions. -2- Section 2. If I nrm, I also want the following: _____________________________________________________________________________ _____________________________________________________________________________ _____________ a tube or an IV if I am permanently unconscious. _______ Yes ______ No OTHER DIRECTIONS: Please list any other things you want done or not done. In addition to the directions I have listed on this fogh a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me. Place your initials by either "yes" or "no": I want to have food and water provided through_____ Yes ____ No Artificially provided food and hydration (Food and water through a tube or an IV) - I understand that if I become permanently unconscious, I may need to be given food and water throull still get medicines and treatments that ease my pain and keep me comfortable. Place your initials by either "yes" or "no": I want to have life-sustaining treatment if I am permanently unconscious. Life sustaining treatment includes drugs, machines, or other medical procedures that would keep me alive but would not cure me. I know that even if I choose not to have life sustaining treatment, I wiout hope for improvement and have watched me long enough to make that decision. I understand that at least one of these doctors must be qualified to make such a diagnosis. Life sustaining treatment - tor agree that within a reasonable degree of medical certainty I can no longer think, feel anything, knowingly move, or be aware of being alive. They believe this condition will last indefinitely with water provided through a tube or an IV if I am terminally ill or injured. _______ Yes _______ No -1- IF I BECOME PERMANENTLY UNCONSCIOUS: Permanent unconsciousness is when my doctor and another docen food and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me. Place your initials by either "yes" or "no": I want to have food andinally ill or injured. ______ Yes ______ No Artificially provided food and hydration (Food and water through a tube or an IV) - I understand that if I am terminally ill or injured I may need to be givining treatment, I will still get medicines and treatments that ease my pain and keep me comfortable. Place your initials by either "yes" or "no": I want to have life sustaining treatment if I am termife sustaining treatment - Life sustaining treatment includes drugs, machines, or medical procedures that would keep me alive but would not cure me. I know that even if I choose not to have life susta ILL OR INJURED: Terminally ill or injured is when my doctor and another doctor decide that I have a condition that cannot be cured and that I will likely die in the near future from this condition. Lomeone at least 19 years of age of my wishes and asking him or her to write them down. I understand that these directions will only be used if I am not able to speak for myself. IF I BECOME TERMINALLYng down. I know that at any time I can change my mind about these directions by tearing up this form and writing a new one. I can also do away with these directions by tearing them up and by telling sing of sound mind and at least 19 years old, would like to make the following wishes known. I direct that my family, my doctors and health care workers, and all others follow the directions I am writie directive, be sure that your doctor, family, and friends know you have one and know where it is located. Section 1. Living Will I, _______________________________________________________________, bes known about what medical treatment or other care you would or would not want if you become too sick to speak for yourself. You are not required to have an advance directive. If you do have an advanche Disclaimers and Terms of Use found at findlegalforms.com -3- Advance Directive for Health Care (Living Will and Health Care Proxy) This form may be used in the State of Alabama to make your wishecument is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to tng with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a dod and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulti"as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intendelly provided nutrition or hydration, shall take precedence over a living will of a Declarant, unless the Declarant's living will or proxy designation indicates otherwise. [_] These forms are provided ng will and a proxy designation, the decisions by the health care proxy duly designated under this chapter regarding the providing, withholding, or withdrawal of life-sustaining treatment or artificial make the advance directive for health care, or a copy of the advance directive for health care, a part of the Declarant's medical records. -2- (g) In the event a Declarant has executed both a liviclarant to provide a copy of the advance directive for health care to his or her attending physician and other health care providers rendering treatment to the Declarant. The health care provider shal for health care of a Declarant who is known by the attending physician to be pregnant shall have no effect during the course of the Declarant's pregnancy. (f) It shall be the responsibility of the Dehe Declarant and have diagnosed and documented in the medical record that the Declarant has either a terminal illness or injury or is in a state of permanent unconsciousness. (e) The advance directive or her medical treatment; and (2) two physicians, one of whom shall be the attending physician, and one of whom shall be qualified and experienced in making such diagnosis, have personally examined tedical care. (d) An advance directive for health care shall become effective when: (1) The attending physician determines that the Declarant is no longer able to understand, appreciate, and direct his of the estate of the Declarant according to the laws of intestate succession of this state or under any will of the Declarant or codicil thereto, or directly financially responsible for Declarant's m the direction of the person making the advance directive for health care, appointed as the health care proxy therein, related to the Declarant by blood, adoption, or marriage, entitled to any portionn; (3) Dated; and (4) Signed in the presence of two or more witnesses at least 19 years of age, neither of whom shall be the person who signed the advance directive for health care on behalf of and atthis chapter shall be: (1) In writing; (2) Signed by the person making the advance directive for health care, or by another person in the Declarant's presence and by the Declarant's expressed directio health care provider or a nonrelative employee of the patient's health care provider make decisions in the capacity of a health care proxy. (c) Any advance directive for health care made pursuant to ation, the divorce, dissolution, or annulment of marriage of the Declarant revokes the designation of the Declarant's former spouse as health care proxy. (4) Under no circumstances shall the patient's, Section 26-1-2, as the same shall be amended from time to time. (3) Unless otherwise provided in the proxy designation or in an order of divorce, dissolution, or annulment of marriage or legal separithdrawal, or withholding of life-sustaining -1- treatment or artificially provided nutrition and hydration shall be limited to those powers permitted under the Alabama Durable Power of Attorney Acto a health care proxy in an advance directive for health care executed pursuant to this subsection that permit a health care proxy to make general health care decisions not related to the provision, ws shall be the same as the authority granted in this chapter to a health care proxy. The appointment shall be limited to the specific directions enumerated in the appointment. (2) Any powers granted t of this chapter a proxy designating another individual to act for the Declarant pursuant to this subsection, provided, however, that the authority granted to an attorney-in-fact to make such decision, or withdrawing of life-sustaining treatment or artificially provided nutrition and hydration in instances involving terminal illness or injury and permanent unconsciousness, constitutes for purposesg will. (1) The designation of an attorney-in-fact, made pursuant to Section 26-1-2, as amended from time to time, who is specifically authorized to make decisions regarding the providing, withholdinged in writing by the individual being appointed. The acceptance shall be evidenced in writing and attached to the proxy designation. The proxy designation may be a separate document or part of a livind nutrition and hydration shall not be withdrawn or withheld pursuant to the proxy designation unless specifically authorized therein. A proxy designation made pursuant to this section shall be acceptnting another competent adult to make decisions regarding the providing, withholding, or withdrawal of life-sustaining treatment and artificially provided nutrition and hydration. Artificially provide or withheld pursuant to the living will unless specifically authorized therein. (b) A competent adult may execute at any time a living will that includes a written health care proxy designation appoidirecting the providing, withholding, or withdrawal of life-sustaining treatment and artificially provided nutrition and hydration. Artificially provided nutrition and hydration shall not be withdrawnrelating to the Alabama Power of Attorney for Health Care Form. Section 22-8A-4 Advance Directive for Health Care; living will and health care proxy. (a) Any competent adult may execute a living will Directive for Health Care includes a Power of Attorney for Health Care and a Living Will and is based on Alabama Statutes Section 22-8A-4. The following are useful excerpts from the Alabama Statutes ective for Health Care (Power of Attorney for Health Care and Living Will); (2) Alabama Advance Directive for Health Care (Power of Attorney for Health Care and Living Will) Form. This Alabama AdvanceInformation and Instructions Alabama Advance Directive for Health Care (Power of Attorney for Health Care and Living Will) This package contains (1) Information and Instruction for Alabama Advance Dir Alabama