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Michigan __________ _______________________________________________________ 2 _______________________________ Signed by witness: _________________________________________ Name of Witness: _________________________________________ Address: ______________________________________gned by witness: _________________________________________ Name of Witness: _________________________________________ Address: ________________________________________________ ________________________witnesses. This declaration was signed in our presence by the Declarant who appears to be of sound mind, and to be making this declaration voluntarily without any duress, fraud or undue influence. Si_________ Address: _______________________________________________________________ _______________________________________________________________________ 1 STATEMENT OF WITNESSES We sign below as t as the original document. I sign this document after careful consideration. I understand it's meaning and I accept its consequences. Signed: ___________________________________________ Dated: _____tion at any time by communicating in any form or manner that this declaration does not reflect my wishes. Photocopies of this signed and witnessed declaration shall have the same legal force and effecs, nurses and other medical personne l involved in my care shall have no civil or criminal liability for following my wishes as expressed in this document. I may change my mind and revoke this declara_________________________________________________________________________ ______________________________________________________________________________ My family, the medical facility, and any doctor____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____e or consent to medical treatment. My desires concerning medical treatment are ______________________________________________________________________________ __________________________________________ll or permanently unconscious and if I am unable to participate in decisions regarding my medical care, it is my intention that this declaration be honored as the expression of my legal right to refus____________________________, (Name of Declarant) being of sound mind, voluntarily make this declaration. In the event my doctor and at least one other doctor determine that I have become terminally ied with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION I,______________________________ts your particular 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 discussdvice. 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 or signed without consulting an attorney first to make sure it fi 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 are not a substitute for legal and/or tax ahis Michigan Living Will is based in part on Chapter 700 Act 386 Section 700.5501 et. Seq. of the Michigan Compiled Laws. [_] These forms are provided "as is" and no implied or express warranties havedress of successor Patient Advocate) -5- Information and Instructions Michigan Living Will This package contains (1) Information and Instruction for Michigan Living Will; (2) Michigan Living Will. Tate ______________. Signed: _____________________________ (Signature of successor patient advocate) Dated: ________________ ______________________________________________________________________ (Adove conditions and I accept the designation as patient advocate for _______________________________________ (Name of patient), who signed a durable power of attorney for health care on the following d_______________________________ (Address of Patient Advocate) SIGNATURE OF SUCCESSOR PATIENT ADVOCATE I, ______________________________________, (Name of successor patient advocate) understand the abf attorney for health care on the following date ______________. Signed: _____________________________ (Signature of patient advocate) Dated: ________________ _______________________________________ (Name of patient advocate) understand the above conditions and I accept the designation as patient advocate for _______________________________________ (Name of patient), who signed a durable power oon 20201 of the Public Health Code, Act No. 368 of Public Acts of 1978, being Section 333.20201 of the Michigan Compiled Laws. SIGNATURE OF PATIENT ADVOCATE I, ______________________________________, her acceptance to the designation at any time and in any manner sufficient to communicate an intent to revoke. (i) A patient admitted to a health facility or agency has the rights enumerated in Sectihe patient's best interests. (g) A patient may revoke his or her designation at any time and in any manner sufficient to communicate an intent to revoke. -4- (h) A patient advocate may revoke his oract consistent with the patient's best interest. The known desires of the patient expressed or evidenced while the patient is able to participate in medical treatment decisions are presumed to be in trmance of his or her authority, rights, and responsibilities. (f) A patient advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the patient and shall all not receive compensation for the performance of his or her authority, rights, and responsibilities, but a patient advocate may be reimbursed for actual and necessary expenses incurred in the perfoncing manner that the patient advocate is authorized to make such a decision, and that the patient acknowledges that such a decision could or would allow the patient's death. (e) A patient advocate sh in the pregnant patient's death. (d) A patient advocate may make a decision to withhold or withdraw treatment which would allow a patient to die only if the patient has expressed in a clear and convin, could not have exercised on his or her own behalf. (c) This designation cannot be used to make a medical treatment to withhold or withdraw treatment from a patient who is pregnant that would resulttment decisions. (b) A patient advocate shall not exercise powers concerning the patient's care, custody, and medical treatment that the patient, if the patient were able to participate in the decisioepts the Principal's designation and appointment as stated in this document and agrees that: (a) This designation shall not become effective unless the patient is unable to participate in medical trearess: __________________________________ __________________________________ ACCEPTANCE BY PATIENT ADVOCATE By signing below, the patient advocate (and successor patient advocate, if one is named) acc_____ Address: __________________________________ __________________________________ Signature of witness 2: __________________________________ Print name here: __________________________________ Addwhere the person who signed this instrument resides. We are at least eighteen years old. -3- Signature of witness 1: __________________________________ Print name here: _____________________________ we an employee of a life or health insurance provider for, or an employee for a health facility that is treating, the person who signed this instrument, nor are we an employee of a home for the aged e are not entitled to any portion of John Doe's estate according to the laws of Intestate Succession. We are not named as the Patient Advocate or a Successor Patient Advocate in this document. Nor arenfluence. We are not the spouse, parent, child, grandchild, sibling, physician, presumptive heir, or known beneficiary of the will at the time of witnessing of the person who signed this instrument. We person who signed this Document, is personally known to us, that he/she signed this document in our presence, and that he/she appeared to us to be of sound mind and under no duress, fraud or undue ises. This declaration was signed in our presence. The declarant appears to be of sound mind, and to be making this designation voluntarily, without duress, fraud or undue influence. We declare that themployee of a company through which you have life or health insurance, or an employee at the health care facility where you are a patient. STATEMENT AND SIGNATURE OF WITNESSES We sign below as witnes____________________ NOTICE REGARDING WITNESSES You must chose two adult witnesses who will not receive your assets when you die and who are not your spouse, child, grandchild, brother or sister, an this document voluntarily, and I understand its purpose. Signed: (Address) __________________________________ (Your signature) Dated: ___________ ___________________________________________________ attorney, but he or she shall be entitled to reimbursement for actual and necessary expenses incurred as a result of carrying out his or her responsibilities as my patient advocate. SIGNATURE I sign of my wishes. -2- Photocopies of this document can be relied upon as though they were originals. My patient advocate shall not be entitled to compensation for services performed under this power ofor my care and there is no patient advocate or successor patient advocate to act for me, I request that the instructions I have given in this document be followed and be considered conclusive evidenceocate pursuant to this document, without actual notice that this power has been revoked or amended, shall incur any liability to me or to my estate. If I am unable to participate in making decisions f time by communicating in any manner that this designation does not reflect my wishes. No person or entity that relies in good faith on the instructions of my patient advocate or successor patient advy wishes in this document. This choice shall not be interpreted as limiting the power of my patient advocate to make any particular decision in any particular circumstance. I may change my mind at any_______________________________________ _______________________________________________________________ _______________________________________________________________ OR B. I choose not to express an_______________________________________________ _______________________________________________________________ _______________________________________________________________ ________________________state no wishes at all. A. My wishes are as follows (you may attach additional sheets of paper) (if none, write "none") _______________________________________________________________ ________________ss general wishes regarding conditions such as terminal illness, permanent unconsciousness, or other disability; specify particular types of treatment I do or not want in such circumstances; or I may ecute waivers, medical authorizations and such other approval as may be required to permit or authorize care which I may need, or to discontinue care that I am receiving. In this document, I can expre; C. To give an informed consent or an informed refusal on my behalf with respect to any medical care; diagnostic, surgical or therapeutic procedure; or other treatment of any type or nature. D. To exss to and control over my medical and personal information; B. To employ and discharge physician, nurses, therapists and any other care providers, and to pay them reasonable compensation with my funds custody and medical treatment, my advocate shall have the power to make each and every judgment for the proper and adequate care and custody of my person, including by not limited to: A. To have acceame if you wish to give your patient advocate this authority) -1- STATEMENT OF WISHES My patient advocate has authority to make decisions in a wide variety of circumstances. With respect to my care, decisions to withhold or withdraw treatment, which would allow me to die, and I acknowledge such decisions could or would allow my death. ________________________________________________ (Sign your nunds. My patient advocate shall have access to any of my medical records to which I have a right. POWER REGARDING LIFE-SUSTAINING TREATMENT (OPTIONAL) I expressly authorize my patient advocate to makerity to consent to or refuse treatment on my behalf, to arrange medical and personal services for me, including admission to a hospital or nursing care facility, and to pay for such services with my faking decisions, my patient advocate shall endeavor to follow my previously expressed wishes, whether I have stated them orally, in a living will, or in this designation. My patient advocate has autho termination by law. My attending physician and another physician or licensed psychologist shall determine, after examining me, when I am unable to participate in making my own medical decisions. In mt that I am unable to participate in decisions about my own medical treatment. Unless revoked by me, this Durable Power of Attorney for Health Care shall remain in effect until my death, revocation or is a durable power of attorney and its validity shall not be affected by my subsequent disability or incapacity. This Durable Power of Attorney for Health Care shall become effective only in the even patient advocate or successor patient advocate (collectively referred to as patient advocate) may delegate his or her powers to the next successor patient advocate if he or she is unable to act. This__________________________________________ _______________________________________________________________________ (Address of successor patient advocate) to serve as my successor patient advocate. Mymoved or cannot serve, I designate _________________________________________ (Name of successor patient advocate) my ___________________________, (relation i.e. spouse, child, friend ...) living at ___________________________________________________________ (Address of patient advocate) as my patient advocate. If my first choice as patient advocate does not accept, is incapacitated, resigns, is reily make this designation. I designate _____________________________ (name of patient advocate), my _________________ (relation i.e. spouse, child, friend ...) living at _______________ ______________and Terms of Use found at findlegalforms.com Durable Power Of Attorney For Health Care I, _____________________________________________ (Print or type your full name), am of sound mind and I voluntarake sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. The purchase and use of these forms is subject to the Disclaimers . 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 it to m Durable Power Of Attorney For Health Care for use in the State of Michigan. These forms are not intended and are not a substitute for legal advice. Laws vary from time to time and from state to stateith a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Michigan Durable Power Of Attorney For Health Care This is aour particular 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 we. 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 or signed without consulting an attorney first to make sure it fits yn 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 are not a substitute for legal and/or tax advicealth Care 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 beeMichigan Advance Health Care Directive This package contains both a Michigan Power of Attorney for Health Care and a Michigan Living Will. Together these forms are also sometimes known as an Advance H Michigan