$17.95

Add to cart

Hawaii executed it. Notary Seal ____________________________ (Signature of Notary Public) -6- _________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she _________ On this _____________ day of ____________________, in the year _______, before me, _____________________________________________ (insert name of notary public) appeared ___________________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ ALTERNATIVE NO. 2 State of Hawaii County of _______ not the person appointed as agent by this document, and that I am not a health-care provider, nor an employee of a health-care provider or facility. Date: ____________________________ ______________n to me, that the principal signed or acknowledged this power of attorney in my presence, that the principal appears to be of sound mind and under no -5- duress, fraud, or undue influence, that I am________ Address: ______________________________________ Witness I declare under penalty of false swearing pursuant to section 710-1062, Hawaii Revised Statutes, that the principal is personally knowprincipal under a will now existing or by operation of law. Date: ____________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________der or facility. I am not related to the principal by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the ound mind and under no duress, fraud, or undue influence, that I am not the person appointed as agent by this document, and that I am not a health-care provider, nor an employee of a health-care provi 710-1062, Hawaii Revised Statutes, that the principal is personally known to me, that the principal signed or acknowledged this power of attorney in my presence, that the principal appears to be of sblic in the State. ____________________________ (sign your name) ____________________________ (print your name) ALTERNATIVE NO. 1 Witness I declare under penalty of false swearing pursuant to section unless it is either (a) signed by two qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature; or (b) acknowledged before a notary pu________ (date) __________________________________ (address) __________________________________ (city) (state) (11) WITNESSES: This power of attorney will not be valid for making health-care decisions____________________________________ (phone) (9) EFFECT OF COPY: A copy of this form has the same effect as the original. -4- (10) SIGNATURES: Sign and date the form here: ________________________________________________ (name of physician) _____________________________________________________________________________ (Address) (city) (state) (zip code) _________________________________________above is not willing, able, or reasonably available to act as my primary physician, I designate the following physician as my primary physician: _____________________________________________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (phone) OPTIONAL: If the physician I have designated nate the following physician as my primary physician: _____________________________________________________________________________ (name of physician) ________________________________________________ o (c) My gift is for the following purposes (strike any of the following you do not want) (i) Transplant (ii) Therapy (iii) Research (iv) Education PART 3 PRIMARY PHYSICIAN (OPTIONAL) (8) I desig o (a) I give any needed organs, tissues, or parts, OR o (b) I give the following organs, tissues, or parts only -3- _________________________________________ ___________________________________________________________________________________________________________________ (Add additional sheets if needed.) PART 2 DONATION OF ORGANS AT DEATH (OPTIONAL) (7) Upon my death: (mark applicable box) to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that: _____________________________________________________________________________ __sonably available to act as guardian, I nominate the alternate agents whom I have named, in the order designated. (6) OTHER WISHES: (If you do not agree with any of the optional choices above and wishwn to my agent. (5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not willing, able, or real make health-care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent knonce with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shalng box. If I mark this box [__], my agent's authority to make health-care decisions for me takes effect immediately. (4) AGENT'S OBLIGATION: My agent shall make health-care decisions for me in accorda3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health-care decisions unless I mark the followi_______ _____________________________________________________________________________ _____________________________________________________________________________ (Add additional sheets if needed.) (r withdraw artificial nutrition and hydration, and all other forms of health care to keep me alive, except as I state here: -2- _______________________________________________________________________________________________________________ (home phone) (work phone) (2) AGENT'S AUTHORITY: My agent is authorized to make all health-care decisions for me, including decisions to provide, withhold, ondividual you choose as second alternate agent) _____________________________________________________________________________ (address) (city) (state) (zip code) ____________________________________ able, or reasonably available to make a health-care decision for me, I designate as my second alternate agent: _____________________________________________________________________________ (name of i_________________________________________________________________________ (home phone) (work phone) OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing,______________________ (name of individual you choose as first alternate agent) _____________________________________________________________________________ (address) (city) (state) (zip code) ____ity or if my agent is not willing, able, or reasonably available to make a health-care decision for me, I designate as my first alternate agent: _________________________________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) OPTIONAL: If I revoke my agent's authorre decisions for me: _____________________________________________________________________________ (name of individual you choose as agent) ___________________________________________________________lth care or replace this form at any time. -1- PART 1 DURABLE POWER OF ATTORNEY FOR HEALTH-CARE DECISIONS (1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health-cald talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility. You have the right to revoke this power of attorney for heaompleted form to your physician, to any other health-care providers you may have, to any health-care institution at which you are receiving care, and to any health-care agents you have named. You shoulity for your health care. After completing this form, sign and date the form at the end and have the form witnessed by one of the two alternative methods listed below. Give a copy of the signed and cDirect the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care. Part 3 of this form lets you designate a physician to have primary responsibidition; (2) Select or discharge health-care providers and institutions; (3) Approve or disapprove diagnostic tests, surgical procedures, programs of medication, and orders not to resuscitate; and (4) hority of your agent, your agent will have the right to: (1) Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental conthe authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health-care decisions that may have to be made. If you choose not to limit the autre institution where you are receiving care. Unless the form you sign limits the authority of your agent, your agent may make all health-care decisions for you. This form has a place for you to limit to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator, or employee of a health-cacisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may name an alternate agent modify all or any part of it. You are free to use a different form. Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health-care deets you name someone else to make health-care decisions for you.. It also lets you express your wishes regarding the designation of your health-care provider. If you use this form, you may complete orTTORNEY FOR HEALTH CARE Explanation You have the right to give instructions about your own health care. You also ha ve the right to name someone else to make health-care decisions for you. This form lng out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -5- POWER OF Ahave an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arisito time and from state to state. These forms should only 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 as to their suitability for any specific purpose or as 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 er advance health-care directive revokes the earlier directive to the extent of the conflict. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided evokes a previous designation of a spouse as agent unless otherwise specified in the decree or in a power of attorney for health care. (e) An advance health-care directive that conflicts with an earlion to the supervising health-care provider and to any health-care institution at which the patient is receiving care. (d) A decree of annulment, divorce, dissolution of marriage, or legal separation re and in any manner that communicates an intent to revoke. (c) A health-care provider, agent, guardian, or surrogate who is informed of a revocation shall promptly communicate the fact of the revocatiiting or by personally informing the supervising health-care provider. (b) An individual may revoke all or part of an advance he alth-care directive, other than the designation of an agent, at any tim compliance with the laws of the state where it was executed. [§327E-4] Revocation of advance health-care directive. -4- (a) An individual may revoke the designation of an agent only by a signed wrude the individual's nomination of a guardian of the person. (j) An advance health-care directive shall be valid for purposes of this chapter if it complies with this chapter, or if it was executed in values to the extent known to the agent. (h) A health-care decision made by an agent for a principal shall be effective without judicial approval. (i) A written advance health-care directive may inclt shall make the decision in accordance with the agent's determination of the principal's best interest. In determining the principal's best interest, the agent shall consider the principal's personalry physician. (g) An agent shall make a health-care decision in accordance with the principal's individua l instructions, if any, and other wishes to the extent known to the agent. Otherwise, the agene, a determination that an individual lacks or ha s recovered capacity, or that another condition exists that affects an individual instruction or the authority of an agent, shall be made by the priman that the principal lacks capacity, and ceases to be effective upon a determination that the principal has recovered capacity. (f) Unless otherwise specified in a written advance health-care directivtorney for health care or by operation of law then existing. (e) Unless otherwise specified in a power of attorney for health care, the authority of an agent becomes effective only upon a determinatioption; nor (2) Entitled to any portion of the estate of the principal upon the principal's death under any will or codicil thereto of the principal existing at the time of execution of the power of ator (3) The agent. (d) At least one of the individuals used as a witness for a power of attorney for health care shall be someone who is neither: (1) Related to the principal by blood, marriage, or ado a notary public at any place within this State. (c) A witness for a power of attorney for health care shall not be: (1) A health-care provider; (2) An employee of a health-care provider or facility; ast two individuals, each of whom witnessed either the signing of the instrument by the principal or the principal's acknowledgment of the signature of the instrument; or -3- (2) Acknowledged beforeich the principal is receiving care. The power shall be in writing, contain the date of its execution, be signed by the principal, and be witnessed by one of the following methods: (1) Signed by at lecity and may include individual instructions. Unless related to the principal by blood, marriage, or adoption, an age nt may not be an owner, operator, or employee of the health-care institution at whealth care, which may authorize the agent to make any health-care decision the principal could have made while having capacity. The power remains in effect notwithstanding the principal's later incapaion. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises. (b) An adult or emancipated minor may execute a power of attorney for h or guardian, authorized under this chapter to make a health-care decision for the patient. [§327E-3] Advance health-care directives. (a) An adult or emancipated minor may give an individual instructesignee, or the health-care provider or the provider's designee who has undertaken primary responsibility for an individual's health care. "Surrogate" means an individual, other than a patient's agent Commonwealth of Puerto Rico, or a territory or insular possession subject to the jurisdiction of the United States. "Supervising health-care provider" means the primary physician or the physician's d health care needs, and willing and able to act in a timely manner considering the urgency of the patient's health care needs. "State" means a state of the United States, the District of Columbia, theasonably available, a physician who undertakes the responsibility. "Reasonably available" means able to be contacted with a level of diligence appropriate to the seriousness and urgency of a patient'sdividual or the individual's agent, guardian, or surrogate, to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not re60. "Power of attorney for health care" means the designation of an agent to make health-care decisions for the individual granting the power. "Primary physician" means a physician designated by an inovernmental subdivision, agency, or instrumentality, or any other legal or commercial entity. -2- "Physician" means an individual authorized to practice medicine or osteopathy under chapter 453 or 4for the patient and who is familiar with the patient's personal values. "Person" means an individual, corporation, business trust, estate, trust, partnership, association, joint venture, government, gted or estranged, a reciprocal beneficiary, any adult child, either parent of the patient, an adult sibling or adult grandchild of the patient, or any adult who has exhibited special care and concern e of a profession. "Individual instruction" means an individual's direction concerning a health-care decision for the individual. "Interested persons" means the patient's spouse, unless legally separaary course of business. "Health-care provider" means an individual licensed, certified, or otherwise authorized or permitted by law to provide health care in the ordinary course of business or practic the individual's health care. "Health-care institutio n" means an institution, facility, or agency licensed, certified, or otherwise authorized or permitted by law to provide health care in the ordined health care standards applicable to health-care providers or institutions. "Health-care decision" means a decision made by an individual or the individual's agent, guardian, or surrogate, regardinge; and (3) Direction to provide, withhold, or withdraw artificial nutrition and hydration; provided that withholding or withdrawing artificial nutrition or hydration is in accord with generally acceptuding: (1) Selection and discharge of health-care providers and institutions; (2) Approval or disapproval of diagnostic tests, surgical procedures, programs of medication, and orders not to resuscitate a health-care decision for an individual. "Health care" means any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect an individual's physical or mental condition, incllth-care decision. "Emancipated minor" means a person under eighteen years of age who is totally selfsupporting. "Guardian" means a judicially appointed guardian or conservator having authority to maktermining benefits and burdens. -1- "Capacity" means an individual's ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a heatreatment or the withholding of treatment; and (7) The religious beliefs and basic values of the individual receiving treatment, to the extent that these may assist the surrogate decision- maker in de (4) The effect of the treatment on the life expectancy of the patient; (5) The prognosis of the patient for recovery, with and without the treatment; (6) The risks, side effects, and benefits of the r withdrawal of the treatment; (3) The degree to which the individua l's medical condition, the treatment, or the withholding or withdrawal of treatment, results in a severe and continuing impairment;effect of the treatment on the physical, emotional, and cognitive functions of the patient; (2) The degree of physical pain or discomfort caused to the individual by the treatment or the withholding oranting the power. "Best interest" means that the benefits to the individual resulting from a treatment outweigh the burdens to the individual resulting from that treatment and shall include: (1) The eans an individual instruction or a power of attorney for health care. "Agent" means an individual designated in a power of attorney for health care to make a health-care decision for the individual gawaii Statutes relating to the Hawaii Advance Health Care Directive Form. [§327E-2] Definitions. Whenever used in this chapter, unless the context otherwise requires: "Advance health-care directive" mor Health Care Form This Hawaii Power of Attorney for Health Care is based in part on Volume 6 Chapter 327E Section 327E-2 et. Seq. of the Hawaii Statutes. The following are useful excerpts from the HInformation and Instructions Hawaii Power of Attorney for Health Care This package contains (1) Information and Instruction for Hawaii Power of Attorney for Health Care; (2) Hawaii Power of Attorney f Hawaii