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Alabama ______ Date: ______________________________ -4- _____________________________________________, am willing to serve as the health care proxy if the first choice cannot serve. Signature: _______________________________________________________________ve as the health care proxy. Signature: _____________________________________________________________________ Date: ______________________________ Signature of Second Choice for Proxy: I, _______________________________________________________________ Date: ______________________________ Section 5. Signature of Proxy I, _________________________________________________________, am willing to ser____________________________________________ -3- Dated: ______________________________ Name of second witness: _________________________________________________________ Signature: _________________s of age and am not directly responsible for paying for his or her medical care. Name of first witness: ___________________________________________________________ Signature: _________________________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 entitled to any part of his or her estate. I am at least 19 year_____________________________________________________________ Section 4. Witnesses (two witnesses need to sign) I am witnessing this form because I believe this person to be of sound mind. I did not ____________ The month, day, and year of your birth: _____________________________________________ Your signature: _________________________________________________________________ Date signed: ______you do not have other directions, place your initials here: ________ No, I do not have any other directions. Section 3. My signature Your name: ______________________________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ If _ OTHER DIRECTIONS: Please list any other things you want done or not done. In addition to the directions I have listed on this form, I also want the following: ______________________________________nd bad points of doing this, along with my wishes, with my health care proxy, if I have one, and with the following people: ____________________________________________________________________________d until after the birth of the baby. -2- 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 aions I have listed, they must see that I get to a doctor or hospit al 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 followehing different from what I have listed on this form. Section 2. 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 directons as listed on this 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 sometNo Place your initials by only one of the following: _______ 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 directitructions for Proxy Place your 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 _________ __________________________ City: ___________________________________ State: ___________________ Zip: _________ Day-time phone number: __________________ Night-time phone number: _________________ Insproxy: _________________________________________________________ Relationship to me: _____________________________________________________________ Address: ____________________________________________e number: __________________ 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 ________________ Address: ______________________________________________________________________ City: ___________________________________ State: ___________________ Zip: _________ -1- Day-time phony. I have talked with this person about my wishes. First choice for proxy: ___________________________________________________________ Relationship to me: _____________________________________________your initials by only 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 proxlast indefinitely without 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. Place doctor and another doctor 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 njured 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. Permanent unconsciousness is when my er 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 TERMINALLY ILL OR INJURED OR PERMANENTLY UNCONSCIOUS: Terminally ill or ie 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 someone at least 19 years of age of my wishes and asking him or hthe following wishes known. I direct that my family, my doctors and health care workers, and all others follow the directions I am writing down. I know that at any time I can change my mind about thesou do not name a health care proxy. Section 1. Health Care Proxy. I, _______________________________________________________________, being of sound mind and at least 19 years old, would like to make ons for you if you become too sick to speak for yourself. This 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 yimers and Terms of Use found at findlegalforms.com -3- Power of Attorney for Health Care This form can be used in the State of Alabama to name a person you would like to make medical or other decisi 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 the Disclan 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 document is 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 consulting with 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 intended and aretrition or hydration, shall take precedence over a living will of a Declarant, unless the Declarant's living will or proxy designation indicates otherwise. -2- [_] These forms are provided "as is" aroxy designation, the decisions by the health care proxy duly designated under this chapter regarding the providing, withholding, or withdrawal of life-sustaining treatment or artificially provided nue advance directive for health care, or a copy of the advance directive for health care, a part of the Declarant's medical records. (g) In the event a Declarant has executed both a living will and a po 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 shall make thth 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 Declarant tant 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 for healedical 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 the Declarre. (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 or her mstate 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 medical caction 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 portion of the eted; 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 at the direter 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 direction; (3) Daare 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 this chape 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 health c2, as the same shall be amended from time to time. -1- (3) Unless otherwise provided in the proxy designation or in an order of divorce, dissolution, or annulment of marriage or legal separation, th, or withholding of life-sustaining treatment or artificially provided nutrition and hydration shall be limited to those powers permitted under the Alabama Durable Power of Attorney Act, Section 26-1- 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 decisio ns not related to the provision, withdrawal 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 to a healthapter 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 decisions shall beawing of life-sustaining treatment or artificially provided nutrition and hydration in instances involving terminal illness or injury and permanent unconsciousness, constitutes for purposes of this chhe 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, withholding, or withdr 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 living will. (1) Tnd 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 accepted in writing competent adult to make decisions regarding the providing, withholding, or withdrawal of life-sustaining treatment and artificially provided nutrition and hydration. Artificially provided nutrition apursuant 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 appointing another providing, withholding, or withdrawal of life-sustaining treatment and artificially provided nutrition and hydration. Artificially provided nutrition and hydration shall not be withdrawn or withheld e 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 directing they for Health Care Form. This Alabama Power of Attorne y for Health Care is based in part on Alabama Statutes Section 22-8A-4. The following are useful excerpts from the Alabama Statutes relating to thInformation and Instructions Alabama Power of Attorney for Health Care This package contains (1) Information and Instruction for Alabama Power of Attorney for Health Care; (2) Alabama Power of Attorne Alabama