$17.95

Add to cart

District of Columbia ___ Signature: _______________________________ -4- adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal under a currently existing will or by operation of law. Signature: ______________________________________________________________ (AT LEAST 1 OF THE WITNESSES LISTED ABOVE SHALL ALSO SIGN THE FOLLOWING DECLARATION.) I further declare that I am not related to the principal by blood, marriage or ess Signature: ______________________________________________ Home Address: __________________________________________ Print Name: _____________________________________________ Date: ________________________________ Home Address: __________________________________________ Print Name: _____________________________________________ Date: ___________________________________________________ Second Witnorney in fact by this document, nor am I the health-care provider of the principal or an employee of the health-care provider of the principal. First Witness Signature: _______________________________durable power of attorney for health care in my presence, and that the person appears to be of sound mind and under no duress, fraud, or undue -3- influence. I am not the person appointed as the att______________________________________ (Signature) WITNESSES I declare that the person who signed or acknowledged this document is personally known to me, that the person signed or acknowledged this E PURPOSE AND EFFECT OF THIS DOCUMENT. I sign my name to this form on _________________________________________ (date) at: _________________________________________________________________ (address). _________________________________________________________________________ ______________________________________________________________________________ BY MY SIGNATURE I INDICATE THAT I UNDERSTAND TH____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________ (b) SPECIAL PROVISIONS AND LIMITATIONS: ______________________________________________________________________________ ___________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________or as I make known to my attorney in fact in some other way. (a) STATEMENT OF DIRECTIVES CONCERNING LIFE-PROLONGING CARE, TREATMENT, SERVICES, AND PROCEDURES: -2- ___________________________________ which shall take effect if I become incapable of making my own health-care decisions and shall continue during that incapacity. My attorney in fact shall make health-care decisions as I direct below (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) With this document, I intend to create a power of attorney for health care,) (work phone) 2. _____________________________________________________________________________ (name) _____________________________________________________________________________ (address) (city) _________________________________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phones unable to act as my attorney in fact, I appoint the following person to serve in the order listed below: 1. _____________________________________________________________________________ (name) ____in fact also has the authority to talk to health-care personnel, get information and sign forms necessary to carry out these decisions. If the person named as my attorney in fact is not available or iable to make my own health-care decisions. This gives my attorney in fact the power to grant, refuse, or withdraw consent on my behalf for any health-care service, treatment or procedure. My attorney (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) as my attorney in fact to make health-care decisions for me if I become un__________________________________________________________ (name of individual you choose as agent) -1- _____________________________________________________________________________ (address) (city) COPY OF THIS DOCUMENT SHOULD BE INCLUDED IN YOUR MEDICAL RECORD. POWER OF ATTORNEY FOR HEALTH CARE I, ____________________________________________________________, hereby appoint: ___________________THER PERSON TO EXPLAIN IT TO YOU. YOU SHOULD KEEP A COPY OF THIS DOCUMENT AFTER YOU HAVE SIGNED IT. GIVE A COPY TO THE PERSON YOU NAME AS YOUR ATTORNEY IN FACT. IF YOU ARE IN A HEALTH-CARE FACILITY, AEVOKE IN WRITING AND TO PLACE COPIES OF THE REVOCATION WHEREVER THIS DOCUMENT IS LOCATED. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A SOCIAL WORKER, LAWYER, OR OAVE BEEN ADJUDICATED INCOMPETENT, BY NOTIFYING YOUR ATTORNEY IN FACT OR HEALTH-CARE PROVIDER EITHER ORALLY OR IN WRITING. SHOULD YOU REVOKE THE AUTHORITY OF YOUR ATTORNEY IN FACT, IT IS ADVISABLE TO RSTATE IN THIS DOCUMENT ANY TYPE OF TREATMENT THAT YOU DO NOT DESIRE AND ANY THAT YOU WANT TO MAKE SURE YOU RECEIVE. YOU HAVE THE RIGHT TO TAKE AWAY THE AUTHORITY OF YOUR ATTORNEY IN FACT, UNLESS YOU HALLY COMPETENT TO DO SO. IN ADDITION, AFTER YOU HAVE SIGNED THIS DOCUMENT, NO TREATMENT MAY BE GIVEN TO YOU OR STOPPED OVER YOUR OBJECTION IF YOU ARE MENTALLY COMPETENT TO MAKE THAT DECISION. YOU MAY TO MAKE HEALTH-CARE DECISIONS FOR YOU IF YOU CANNOT MAKE THE DECISIONS FOR YOURSELF. AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE HEALTH-CARE DECISIONS FOR YOURSELF IF YOU ARE MENTNT THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, IT IS VITAL FOR YOU TO KNOW AND UNDERSTAND THESE FACTS: THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR ATTORNEY IN FACT THE POWERx professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Power of Attorney for Health Care INFORMATION ABOUT THIS DOCUMEparticular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tanly be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your s to their legal effect or completeness. [_]These forms are not intended 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 opreclude the use of alternative language: [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or arequirements of § 21-2205 may be used to create a durable power of attorney for health care. The following is offered as a sample form only and its inclusion in this section shall not be construed to f the principal to the former spouse but may be subsequently revoked by an act of the principal. § 21-2207. Forms for creating a durable power of attorney for health care Any written form meeting the n of the former spouse as an attorney in fact to make health-care decisions for the principal. If a designation is revoked solely on account of this subsection, it shall be revived by the remarriage oorney for health care expressly provides otherwise, and after its execution the marriage of the principal is dissolved or annulled, the dissolution or annulment shall automatically revoke a designatio Unless it expressly provides otherwise, a valid durable power of attorney for health care revokes any prior durable power of attorney for health-care decisions only. (e) Unless a durable power of attrney in fact of the revocation. (c) There shall be a rebuttable presumption, affecting the burden of proof, that a principal has the capacity to revoke a durable power of attorney for health care. (d)revocation pursuant to subsection (a)(2) of this section, the health-care provider shall document this fact in the patient-care records of the principal and make a reasonable effort to notify the atto decisions granted to the attorney in fact under a durable power of attorney for health care by notifying the health-care provider orally or in writing. (b) If a health-care provider is notified of a Revoke the appointment of the attorney in fact under a durable power of attorney for health care by notifying the attorney in fact orally or in writing; or (2) Revoke the authority to make health-carecare decisions on behalf of the principal. § 21-2208. Revocation -2- (a) At any time that the principal has the capacity to create a durable power of attorney for health care, the principal may: (1) ing in this chapter shall affect any right that an attorney in fact may have, independent of the designation in a durable power of attorney for health care, to make or otherwise participate in health-attorney for health care; or (2) The good faith belief of the attorney in fact as to the best interests of the principal, if the wishes of the principal are unknown and cannot be ascertained. (d) Nothing authority under a durable power of attorney for health care, the attorney in fact shall have a duty to act in accordance with: (1) The wishes of the principal as expressed in the durable power of ted attorney in fact shall not have the authority to make a particular health-care decision, if the principal is able to give or withhold informed consent with respect to that decision. (c) In exercise provider to be available and willing to make a particular health-care decision, shall have priority over any other person to act for the principal in all matters regarding health care. (2) A designaons. (b) (1) Except as provided in paragraph (2) of this subsection and unless a durable power of attorney for health care provides otherwise, the designated attorney in fact, if known to a health-carare professionals; and (5) The authority to make decisions regarding admission to or discharge from healthcare facilities and to take any lawful actions that may be necessary to carry out these decisio review the health care records of the principal; (3) The right to be provided with all information necessary to make informed healthcare decisions; (4) The authority to select and discharge health-cand federal law. This authority shall include, at a minimum: (1) The authority to grant, refuse or withdraw consent to the provision of any healthcare service, treatment, or procedure; (2) The right tons in the durable power of attorney for health care, an attorney in fact shall have all the rights, powers and authority related to health-care decisions that the principal would have under District ompetency shall be effective, if the execution of the prior document meets the requirements of this chapter. -1- § 21-2206. Rights and duties of attorney in fact. (a) Subject to any express limitatipal by a current will or operation of law. (e) Any durable power of attorney for health care executed prior to March 16, 1989, and specifically written to include health-care decision making after inctnesses referred to in subsection (c) of this section, at least 1 shall not be related to the principal by blood, marriage or adoption and shall not be entitled to any part of the estate of the princithe time of signing. The 2 adult witnesses shall not include the principal, the health-care provider of the principal or an employee of the health-care provider of the principal. (d) Of the 2 adult wihe principal." (c) A durable power of attorney for health care shall be dated and signed by the principal and 2 adult witnesses who affirm that the principal was of sound mind and free from duress at y similar to the following: (1) "This power of attorney shall not be affected by the subsequent incapacity of the principal."; or (2) "This power of attorney becomes effective upon the incapacity of tclearly communicates that the principal intends the attorney in fact to have the authority to make health-care decisions on behalf of the principal and shall include language identical or substantiallncapable, by reason of mental disability, of making or communicating a choice regarding a particular health-care decision. (b) A durable power of attorney for health care shall include language which for health care. (a) A competent adult may designate, in writing, an individual who shall be empowered to make health-care decisions on behalf of the competent adult, if the competent adult becomes iolumbia Code. The following are useful excerpts from the District of Columbia Statutes relating to the District of Columbia Power of Attorney for Health Care Form. § 21-2205. Durable power of attorney) District of Columbia Power of Attorney for Health Care Form. This District of Columbia Power of Attorney for Health Care is based on Title 21 Chapter 22 Section 21-2205 et. Seq. of the District of CInformation and Instructions District of Columbia Power of Attorney for Health Care This package contains (1) Information and Instruction for District of Columbia Power of Attorney for Health Care; (2 District of Columbia