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Idaho __________________________ Name: ____________________________________________________________________ Address: __________________________________________________________________ 2 e: ____________________________________________________________________ Address: __________________________________________________________________ Witness Signature: ___________________________________________________________ The declarant has been known to me personally and I believe him/her to be of sound mind. Witness Signature: __________________________________________________________ NamName: ____________________________________________________________________ Address: __________________________________________________________________ ______________________________________ Zip Code: __________________________________________ ____________________________________________________________________________ Declarant's Signature: _______________________________________________________ ally or socially, for complying with my directions. Additional Instructions (optional): ____________________________________________________________________________ __________________________________aking of this directive or in its being carried into effect, whether it be a medical doctor, my spouse, a relative, friend or any other person shall be held responsible in any way, legally, professione shall have no force during the course of my pregnancy. 5. I understand the full importance of this directive and am emotionally and mentally competent to make this directive. No participant in the muse or accept medical and surgical treatment, and I accept the consequences of such refusal. 4. If I have been diagnosed as pregnant and that diagnosis is known to any interested person, this directivtions regarding my treatment, including life-sustaining procedures, it is my intention that this directive shall be honored by my family and physicians as the final expression of my legal right to refent; and I accept the consequences of such a decision. I have duly executed a Durable Power of Attorney for health care decisions on this date. 1 3. In the absence of my ability to give further direcs my intention that this appointment shall be honored by him/her, by my family, relatives, friends, physicians and lawyer as the final expression of my legal right to refuse medical or surgical treatm___________ (name) currently residing at _________________________________________ (address) as my attorney- in- fact/proxy for the making of decisions relating to my health care in my place; and it i of the administration of nutrition and hydration. 2. In the absence of my ability to give directions regarding the use of life-sustaining procedures, I hereby appoint ________________________________instructions and where the application of artificial life-sustaining procedures shall serve only to prolong artificially my life, I direct such procedures be withheld or withdrawn including withdrawalo prolong artificially my life, I direct such procedures be withheld or withdrawn except for the administration of nutrition and hydration. o If at any time I should become unable to communicate my my injury, disease, illness or condition. o If at any time I should become unable to communicate my instructions and where the application of artificial life-sustaining procedures shall serve only tfe, and to abolish or alleviate pain or distress be provided to me. Nutrition and hydration shall not be withheld or withdrawn from me if I would die from malnutrition or dehydration rather than from o x" o If at any time I should become unable to communicate my instructions, then I direct that all medical treatment, care, and nutrition and hydration necessary to restore my health, sustain my lied expression of my intent be followed and that I be permitted to die naturally, and that I receive any medical treatment or care that may be required to keep me free of pain or distress. "Check One Bdoctor determines that my death is imminent, whether or not lifesustaining procedures are utilized, or I have been diagnosed as being in a persistent vegetative state, I direct that the following mark be terminal by two (2) medical doctors who have examined me, and where the application of life-sustaining procedures of any kind would serve only to prolong artificially my life, and where a medical my life shall not be prolonged artificially under the circumstances set forth below, do hereby declare: 1. If at any time I should have an incurable injury, disease, illness or condition certified toall others whom it may concern: Directive made this _____ day of _________, 20___ I, ________________________________. (name), being of sound mind, willfully, and voluntarily make known my desire thatt to the Disclaimers and Terms of Use found at findlegalforms.com Living Will A Directive to Withhold or to Provide Treatment To my family, my relatives, my friends, my physicians, my employers, and ded when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subjecd only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommenr 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 to time and from state to state. These forms shoulson has actual knowledge of the revocation. [_] 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 ot to revoke the directive. (2) There shall be no criminal or civil liability on the part of any person for failure to act upon a revocation of a directive made pursuant to this section unless that perome person in his presence and by his direction. (b) By a written, signed, revocation of the maker thereof expressing his intent to revoke. (c) By a verbal expression by the maker thereof of his inteneof, without regard to his mental state or competence, by any of the following methods: (a) By being cancelled, defaced, obliterated or burned, torn or otherwise destroyed by the maker thereof or by she intent of the legislature that the procedures described herein are the only effective means of such communication. 39-4506. REVOCATION. (1) A directive may be revoked at any time by the maker thercedures carried out even though that person is no longer able to communicate with the physician. It is the intent of the legislature to establish an effective means for such communication. It is not tegislature hereby declares that the laws of this state shall recognize the right of a competent person to have his wishes for medical treatment and for the withdrawal of artificial life sustaining proally necessary or beneficial to the patient because of the patient's inability to communicate with the physician. In recognition of the dignity and privacy which patients have a right to expect, the latural limits. The legislature further finds that patients are sometimes unable to express their desire to withhold or withdraw such artificial life prolongation procedures which provide nothing medicthe decision to have life sustaining procedures withheld or withdrawn. The legislature further finds that modern medical technology has made possible the artificial prolongation of human life beyond ne legislature finds that adult persons have the fundamental right to control the decisions relating to the rendering of their medical care, Living Will Information & Instructions ­ Page 2 including er of attorney for health care" means a durable power of attorney to the extent that it authorizes an attorney in fact to make health care decisions for the principal. 39-4502. STATEMENT OF POLICY. Thgetative state. Artificial lifesustaining procedures shall not include the administration of medication or the performance of any medical procedure deemed necessary to alleviate pain. (4) "Durable pow artificially prolong life and where, in the judgment of the attending physician, death is imminent whether or not such procedures are utilized, or the patient is diagnosed as being in a persistent vesustaining procedure" means any medical procedure or intervention which utilizes mechanical means to sustain or supplant a vital function which when applied to a qualified patient, would serve only toesponsibility for the treatment and care of the patient. (2) "Competent person" means any emancipated minor or any person eighteen (18) or more years of age who is of sound mind. (3) "Artificial life-nitions shall govern the construction of this chapter: (1) "Attending physician" means the physician licensed by the state board of medicine, selected by, or assigned to, the patient who has primary r another fo rm that contains the elements set forth in this section. 39-4501. SHORT TITLE. This act shall be known and may be cited as the "Natural Death Act." 39-4503. DEFINITIONS. The following defiTLE 39 (HEALTH AND SAFETY) CHAPTER 45 (NATURAL DEATH ACT) 39-4504. LIVING WILL. Any competent person may execute a document known as a "living will." Such document shall be in the following form or in Living Will is based on Title 39 Chapter 45 Section 39-4504 et. Seq. of the Idaho Statutes. For your convenience, we have included useful excerpts from the Idaho Statutes relating to Living Wills. TI______________ (Signature of Notary) -5- Information and Instructions Idaho Living Will This package contains (1) Information and Instruction for Idaho Living Will; (2) Idaho Living Will. This Idaho declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence. _______________________________ name of signer of instrument) to me known (or proved to me on basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed it. Iument.) State of Idaho County of _____________________________________________ ss. On this __________ day of _____________ 20_______.... before me personally appeared ___________________________ (full -4- Signature: _____________________________________________ NOTARY (Signer of instrument may either have it witnessed as above or have his/her signature notarized as below, to legalize this instr I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law. Signature: _____________________________________________e witnesses must also sign) I further declare under penalty of perjury under the laws of Idaho that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge,___________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _______________________________________ (At least one of the abov__ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _______________________________________ __________________________________re provider, an employee of a health care provider, the operator of a community care facility, nor an employee of an operator of a community care facility. ___________________________________________e, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as attorney in fact by this document, and that I am not a health cahis document is personally known to me (or proved to me on the basis of convincing evidence) to be the principal, that the principal signed or acknowledged this durable power of attorney in my presencsses must make the additional declaration set out following the place where the witnesses sign.) I declare under penalty of perjury under the laws of Idaho that the person who signed or acknowledged ta health care provider, (3) an employee of a health care provider, (4) the operator of a community care facility, (5) an employee of an operator of a community care facility. At least one of the witneTEMENT OF WITNESSES (This document must be witnessed by two qualified adult witnesses. None of the following may be used as a witness: (1) a person you designate as your agent or alternate agent, (2) ledge your signature. If you have attached any additional pages -3- to this form, you must date and sign each of the additional pages at the same time you date and sign this Power of Attorney.) STA______ (State) ________________________________________ (You sign here) (This Power of Attorney will not be valid unless it is signed by two qualified witnesses who are present when you sign or acknow my name to this Statutory Form Durable Power of Attorney for Health Care on ______________________ at _______________________ , _______________ (Date) _________________________ (City) _______________nd alternate agent) 8. PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney for health care. DATE AND SIGNATURE OF PRINCIPAL (You Must Date and Sign This Power of Attorney) I signnsert name, address, and telephone number of first alternate agent) B. Second Alternate Agent ______________________________________________________ (Insert name, address, and telephone number of seco make health care decisions for me as authorized in this document, such persons to serve in the order listed below: A. First Alternate Agent ________________________________________________________ (Iisions for me, or if I revoke that person's appointment or authority to act as my agent to make health care decisions for me, then I designate and appoint the following persons to serve as my agent toIf the person designated as my agent in paragraph 1 is not available or becomes ineligible to act as my agent to make a health care decision for me or loses the mental capacity to make health care decve, in the event that agent is unable or ineligible to act as your agent. If the agent you designated is your spouse, he or she becomes ineligible to act as your agent if your marriage is dissolved.) not required to designate any alternate agents but you may do so. Any alternate agent you designate will be able to make the same health care decisions as the agent you designated in paragraph 1, aboo Permit Treatment" and "Leaving Hospital Against Medical Advice." (b) Any necessary waiver or release from liability required by a hospital or physician. 7. DESIGNATION OF ALTERNATE AGENTS. (You areons that my agent is authorized by this document to make, my agent has the power and authority to execute on my behalf all of the following: -2- (a) Documents titled or purporting to be a "Refusal te the limitations in paragraph 4 ("Statement of Desires, Special Provisions, and Limitations") above.) 6. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to implement the health care decisition. (d) Consent to the donation of any of my organs for medical purposes. (If you want to limit the authority of your agent to receive and disclose information relating to your health, you must statmited to, medical and hospital records. (b) Execute on my behalf any releases or other documents that may be required in order to obtain this information. (c) Consent to the disclosure of this informaent, my agent has the power and authority to do all of the following: (a) Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not li the additional pages at the same time you date and sign this document.) 5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this docum_____________________________________________________ (You may attach additional pages if you need more space to complete your statement. If you attach additional pages, you must date and sign each ofs, and limitations: _____________________________________________________________________________ _____________________________________________________________________________ ________________________, my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated in the living will. Additional statement of desires, special provisionl have broad powers to make health care decisions for you, except to the extent that there are limits provided by law.) In exercising the authority under this durable power of attorney for health carespace below. If you want -1- to limit in any other way the authority given your agent by this document, you should state the limits in the space below. If you do not state any limits, your agent wile your desires known to your agent by discussing your desires with your agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them in the r desires concerning life-prolonging care, treatment, services, and procedures. You can also include a statement of your desires concerning other matters relating to your health care. You can also makisions that are consistent with your known desires. You can, but are not required to, state your desires in the space provided below. You should consider whether you want to include a statement of youlow. You can indicate your desires by including a statement of your desires in the same paragraph.) 4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. (Your agent must make health care dec. (If you want to limit the authority of your agent to make health care decisions for you, you can state the limitations in paragraph 4 ("Statement of Desires, Special Provisions, and Limitations") ben this document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedurestent that I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated ipacity. 3. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same exEATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a durable power of attorney for health care. This power of attorney shall not be affected by my subsequent incaalth care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical condition. 2. CRlative employee of an operator of a community care facility). as my attorney in fact (agent) to make health care decisions for me as authorized in this document. For the purposes of this document, "he may be designated as your agent: (1) your treating health care provider, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility, or (4) a nonre____________ _____________________________________________ (Insert name, address, and telephone number of one individual only as your agent to make health care decisions for you. None of the followingth Care 1. DESIGNATION OF HEALTH CARE AGENT. I, ___________________________________________________________________________ (Insert your name and address) do hereby designate and appoint _____________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 -1- Durable Power of Attorney for Healit 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 arising out of this document o 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 have an attorney review 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 to time and from state ther form which contains the elements set forth in the following form. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability ative holders of the power in the event that the first person named is unable or unwilling to exercise the power. A durable power of attorney for health care may be in the following form, or in any otcare may make health decisions for the person to the same extent that the principal could make such decisions given the capacity to do so. The durable power of attorney for health care may list alterndurable power of attorney for health care. The power shall be effective only when the competent person is unable to communicate rationally. The person granted the durable power of attorney for health 4505. DURABLE POWER OF ATTORNEY FOR HEALTH CARE. In order to implement the general desires of a person as expressed in the "living will," a competent person may appoint any adult person to exercise a ased on Title 39 Chapter 45 Section 39-4505 et. Seq. of the Idaho Statutes. The following are useful excerpts from the Idaho Statutes relating to the Idaho Power of Attorney for Health Care Form. 39-e This package contains (1) Information and Instruction for Idaho Power of Attorney for Health Care; (2) Idaho Power of Attorney for Health Care Form. This Idaho Power of Attorney for Health Care is bax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Idaho Power of Attorney for Health Carticular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a t 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 or signed without consulting an attorney first to make sure it fits your paror are provided 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. Lawsre Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have been made Idaho Advance Health Care Directive This package contains both a Idaho Power of Attorney for Health Care and a Idaho Living Will. Together these forms are also sometimes known as an Advance Health Ca Idaho