$23.95

Add to cart

Minnesota your physician's office and at the hospital, home care agency, hospice, or nursing facility where you receive your care. -8- your doctors, family, close friends, health care agent, and alternate health care agent. Make sure your doctor is willing to follow your wishes. This document should be part of your medical record at_____________________________ Address: ______________________________________ REMINDER: Keep this document with your personal papers in a safe place (not in a safe deposit box). Give signed copies to initial this box: [______________] I certify that the information in (i) through (iv) is true and correct. _____________________________________________ (Signature of Witness Two) Print Name: ______care agent or an alternate health care agent in this document. (iv) If I am a health care provider or an employee of a health care provider giving direct care to the person listed above in (A), I must/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. (ii) I am at least 18 years of age. (iii) I am not named as a health ________________ Address: ______________________________________ Witness Two: (i) In my presence on ________________________ (date), ___________________________________________(name) acknowledged his [______________] I certify that the information in (i) through (iv) is true and correct. _____________________________________________ (Signature of Witness One) -7- Print Name: ___________________lternate health care agent in this document. (iv) If I am a health care provider or an employee of a health care provider giving direct care to the person listed above in (A), I must initial this box:this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. (ii) I am at least 18 years of age. (iii) I am not named as a health care agent or an aect care to me on the day I sign this document. Witness One: (i) In my presence on ________________________ (date), ___________________________________________(name) acknowledged his/her signature on (Signature of Notary) (Notary Stamp) Option 2: Two Witnesses Two witnesses must sign. Only one of the two witnesses can be a health care provider or an employee of a health care provider giving dir the person signing this document to sign on his/her behalf. I am not named as a health care agent or alternate health care agent in this document. ___________________________________________________my presence on ________________________ (date), __________________________________________________________ (name) acknowledged his/her signature on this document or acknowledged that he/she authorizedo sign this document for me) -6- __________________________________________________________________ (Printed name of the person who I asked to sign this document for me) Option 1: Notary Public In ___________________ If I cannot sign my name, I can ask someone to sign this document for me. __________________________________________________________________ (Signature of the person who I asked t_____________________________________ My Signature Date signed: ________________________________ Date of birth: _______________________________ Address: _______________________________________________itnesses (Option 2). It must be dated when it is verified or witnessed. I am thinking clearly, I agree with everything that is written in this document, and I have made this document willingly. _________________________________________________ PART III: MAKING THE DOCUMENT LEGAL This document must be signed by me. It also must either be verified by a notary public (Option 1) OR witnessed by two wr things: _____________________________________________________________________________ _____________________________________________________________________________ __________________________________dy when I die (cremation, burial): _____________________________________________________________________________ _____________________________________________________________________________ Any othe -5- _____________________________________________________________________________ _____________________________________________________________________________ My wishes about what happens to my bo__________________________________________________________________ _____________________________________________________________________________ My wishes about donating parts of my body when I die: ______________________________________________ _____________________________________________________________________________ Where I would like to die and other wishes I have about dying: _________________________________________________ _____________________________________________________________________________ Where I would like to live to receive health care: _________________________________________________________________________ There are other things that I want or do not want for my health care, if possible: Who I would like to be my doctor: _______________________________________feel about pain relief if it would affect my alertness or if it could shorten my life: _____________________________________________________________________________ _________________________________________________________ _____________________________________________________________________________ In all circumstances, my doctors will try to keep me comfortable and reduce my pain. This is how I ___________________________________ If I were completely dependent on others for my care and unable to decide or speak for myself, I would want: _______________________________________________________permanently unconscious and unable to decide or speak for myself, I would want: _____________________________________________________________________________ __________________________________________k for myself, I would want: _____________________________________________________________________________ _____________________________________________________________________________ -4- If I were _____________________________________________________________________________ _____________________________________________________________________________ If I were dying and unable to decide or spea: You can discuss general feelings, specific treatments, or leave any of them blank) If I had a reasonable chance of recovery, and were temporarily unable to decide or speak for myself, I would want: dialysis, antibiotics, and blood transfusions. Most medical treatments can be tried for a while and then stopped if they do not help. I have these views about my health care in these situations: (Noten or to prolong my life. Examples include artificial breathing by a machine connected to a tube in the lungs, artificial feeding or fluids through tubes, attempts to start a stopped heart, surgeries, _______ THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE (I know I can change these choices or leave any of them blank) Many medical treatments may be used to try to improve my medical conditiodition might affect my family: ____________________ _____________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ My thoughts about how my medical con_______________________________________ _____________________________________________________________________________ My beliefs about when life would be no longer worth living: _______________________________________________________________________________________ -3- My spiritual or religious beliefs and traditions: _______________________________________ _______________________________________________________________ My fears about my health care: ____________________________________________________ _____________________________________________________________________________ ____________my health care: _____________________________________________________ _____________________________________________________________________________ ____________________________________________________S AND VALUES ABOUT MY HEALTH CARE (I know I can change these choices or leave any of them blank) I want you to know these things about me to help you make decisions about my health care: My goals for h care directive. These are instructions for my health care when I am unable to decide or speak for myself. These instructions must be followed (so long as they address my needs). THESE ARE MY BELIEFis Part II is optional but would be very helpful to your agent. However, if you chose not to appoint an agent in Part I, you MUST complete some or all of this Part II if you wish to make a valid healt________________________________________ PART II: HEALTH CARE INSTRUCTIONS NOTE: Complete this Part II if you wish to give health care instructions. If you appointed an agent in Part I, completing th here: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________d eyes, when I die. (2) To decide what will happen with my body when I die (burial, cremation). If I want to say anything more about my health care agent's powers or limits on the powers, I can say itany of the powers in (1) and (2), I must INITIAL the line in front of the power; then my agent WILL HAVE that power. (1) To decide whether to donate any parts of my body, including organs, tissues, an _____________________________________________________________________________ -2- My health care agent is NOT automatically given the powers listed below in (1) and (2). If I WANT my agent to have er in (A) through (D), I MUST say that here: _____________________________________________________________________________ _____________________________________________________________________________d have the same rights that I would have to give my medical records to other people. If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR if I want to LIMIT any powe mental health treatment. (B) Choose my health care providers. (C) Choose where I live and receive care and support when those choices relate to my health care needs. (D) Review my medical records an withdraw consent to any care, treatment, service, or procedures. This includes deciding whether to stop or not start health care that is keeping me or might keep me alive, and deciding about intrusivct in my best interest. Whenever I am unable to decide or speak for myself, my health care agent has the power to: (A) Make any health care decision for me. This includes the power to give, refuse, orD). My health care agent must follow my health care instructions in this document or any other instructions I have given to my agent. If I have not given health care instructions, then my agent must aHEALTH CARE AGENT TO BE ABLE TO DO IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF (I know I can change these choices) My health care agent is automatically given the powers listed below in (A) through (___________ Address of my alternate health care agent: __________________________________________ _____________________________________________________________________________ THIS IS WHAT I WANT MY to be my health care agent instead. Relationship of my alternate health care agent to me: __________________________________ Telephone number of my alternate health care agent: _____________________________________________ -1- (OPTIONAL) APPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my health care agent is not reasonably available, I trust and appoint __________________________________________ health care agent: _________________________________________ Address of my health care agent: __________________________________________________ ______________________________________________________________ to make health care decisions for me. This person is called my health care agent. Relationship of my health care agent to me: __________________________________________ Telephone number of my t wish to appoint an agent, you may leave Part I blank and go to Part II. When I am unable to decide or speak for myself, I trust and appoint __________________________________________________________nd I know I do not have to appoint an agent or an alternate agent) NOTE: If you appoint an agent, you should discuss this health care directive with your agent and give your agent a copy. If you do no I: APPOINTMENT OF HEALTH CARE AGENT THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS FOR ME IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF (I know I can change my agent or alternate agent at any time aare to be used by the agent. These instructions may also be used by my health care providers, others assisting with my health care and my family, in the event I cannot make decisions for myself. PARTI have not made my health care wishes known. AND/OR PART II: Give health care instructions to guide others making health care decisions for me. If I have named a health care agent, these instructions are agent must make health care decisions for me based on the instructions I provide in this document (Part II), if any, the wishes I have made known to him or her, or must act in my best interest if allows me to do ONE OR BOTH of the following: PART I: Name another person (called the health care agent) to make health care decisions for me if I am unable to decide or speak for myself. My health crms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -5- Health Care Directive I, _______________________________________________________________, understand this document orney whenever a document is 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 foed 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 particular situation. You should also consult an attrms 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 only be a starting point for you and should not be usforms 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 as to their legal effect or completeness. [_]These fof proceedings for dissolution, annulment, or termination of the principal's -4- marriage or commencement of proceedings for termination of the principal's registered domestic partnership. [_] These th care directive, the appointment by the principal of the principal's spouse or registered domestic partner as health care agent under a health care power of attorney is revoked by the commencement oinstrument. Subd. 2. Effect of dissolution or annulment of marriage or termination of domestic partnership on appointment of health care agent. Unless the principal has otherwise specified in the heale presence of two witnesses who do not have to be present at the same time; or (4) executing a subsequent health care directive, to the extent the subsequent instrument is inconsistent with any prior expressing the principal's intent to revoke the health care directive in whole or in part; (3) verbally expressing the principal's intent to revoke the health care directive in whole or in part in ththe presence of the principal to destroy the health care directive instrument, with the intent to revoke the health care directive in whole or in part; (2) executing a statement, in writing and dated,ole or in part at any time by doing any of the following: (1) canceling, defacing, obliterating, burning, tearing, or otherwise destroying the health care directive instrument or directing another in rwise specified by the principal have been met. 145C.09 Revocation of health care directive. Subdivision 1. Revocation. A principal with the capacity to do so may revoke a health care directive in whctive for a health care decision when the principal, in the determination of the attending physician of the principal, recovers decision- making capacity; or if other conditions for effectiveness otheipal, lacks decision- making capacity to make the health care decision; or if other conditions for effectiveness otherwise specified by the principal have been met. A health care directive is not effective is effective for a health care decision when: (1) it meets the requirements of section 145C.03, subdivision 1; and (2) the principal, in the determination of the attending physician of the princl on the date of execution. A person notarizing a health care directive may be an employee of a health care provider providing direct care to the principal. 145C.06 When effective. A health care dires to the execution of the health care directive must not be a health care provider providing direct care to the principal or an employee of a health care provider providing direct care to the principa a health care power of attorney may not act as a witness or notary public for the execution of the health care directive that includes the health care power of attorney. -3- (b) At least one witnese the health care agent must make decisions for the principal. Subd. 3. Individuals ineligible to act as witnesses or notary public. (a) A health care agent or alternate health care agent appointed inte the health care agent must make decisions for the principal; or (2) an employee of a health care provider attending the principal on the date of execution of the health care directive or on the dation, or unless the principal has otherwise specified in the health care directive: (1) a health care provider attending the principal on the date of execution of the health care directive or on the dab) The following individuals are not eligible to act as the health care agent, unless the individual appointed is related to the principal by blood, marriage, registered domestic partnership, or adoptppointed by the principal under section 145C.05, subdivision 2, paragraph (b), to make the determination of the principal's decision- making capacity is not eligible to act as the health care agent. (s as provided under this chapter; and (6) include a health care instruction, a health care power of attorney, or both. Subd. 2. Individuals ineligible to act as health care agent. (a) An individual aprincipal; (5) contain verification of the principal's signature or the signature of the person authorized by the principal to sign on behalf of the principal, either by a notary public or by witnesserincipal's name; (4) be executed by a principal with capacity to do so with the signature of the principal or with the signature of another person authorized by the principal to sign on behalf of the th care directive. -2- 145C.03 Requirements. Subdivision 1. must: Legal sufficiency. To be legally sufficient in this state, a health care directive (1) be in writing; (2) be dated; (3) state the pagent to make health care decisions for the principal when the principal, in the judgment of the principal's attending physician, lacks decision-making capacity, unless otherwise specified in the heal direct health care providers, others assisting with health care, family members, and a health care agent. A health care directive may include a health care power of attorney to appoint a health care alth care needs. 145C.02 Health care directive. A principal with the capacity to do so may execute a health care directive. A health care directive may include one or more health care instructions to a health care directive. Subd. 9. Reasonably available. "Reasonably available" me ans able to be contacted and willing and able to act in a timely manner considering the urgency of the principal's he means a written statement of the principal's values, preferences, guidelines, or directions regarding health care. Subd. 8. Principal. "Principal" means an individual age 18 or older who has executed44A.02, a home care provider licensed under sections 144A.43 to 144A.47, or a hospice provider licensed under sections 144A.75 to 144A.755. Subd. 7a. Health care instruction. "Health care instruction"er chapter 62D. Subd. 7. Health care facility. "Health care facility" means a hospital or other entity licensed under sections 144.50 to 144.58, a nursing home licensed to serve adults under section 1authorized or permitted by the laws of this state to administer health care directly or through an arrangement with other health care providers, including health maintenance organizations licensed unded under this chapter before August 1, 1998. Subd. 6. Health care provider. "Health care provider" means a person, health care facility, organization, or corporation licensed, certified, or otherwise written instrument that complies with section 145C.03 and includes one or more health care instructions, a health care power of attorney, or both; or a durable power of attorney for health care execut Subd. 5. Health care decision. "Health care decision" means the consent, refusal of consent, or withdrawal of consent to health care. Subd. 5a. Health care directive. "Health care directive" means a the establishment of a person's abode within or without the state and personal security safeguards for a person, to the extent decisions on these matters relate to the health care needs of the person.terally or through intubation but does not -1- include any treatment, service, or procedure that violates the provisions of section 609.215 prohibiting assisted suicide. "Health care" also includes eans any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a person's physical or mental condition. "Health care" includes the provision of nutrition or hydration paren power of attorney. "Health care power of attorney" means an instrument appointing one or more health care agents to make health care decisions for the principal. Subd. 4. Health care. "Health care" mho is appointed by a principal in a health care power of attorney to make health care decisions on behalf of the principal. "Health care agent" may also be referred to as "agent." Subd. 3. Health carecant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. Subd. 2. Health care agent. "Health care agent" means an individual age 18 or older waith if the person violates the provisions of section 609.215 prohibiting assisted suicide. Subd. 1b. Decision- making capacity. "Decision- making capacity" means the ability to understand the signifignosis and the principal's personal values to the extent known. Notwithstanding any instruction of the principal, a health care agent, health care provider, or any other person is not acting in good finformation do not provide adequate guidance to the actor, "act in good faith" means acting in the best interests of the principal, considering the principal's overall general health condition and pro53B.03, subdivision 6d, or information otherwise made known by the principal, unless the actor has actual knowledge of the modification or revocation of the information expressed. If these sources of istently with a legally sufficient health care directive of the principal, a living will executed under chapter 145B, a declaration regarding intrusive mental health treatment executed under section 2ney for Health Care) Form. 145C.01 Definitions. Subdivision 1. Applicability. The definitions in this section apply to this chapter. Subd. 1a. Act in good faith. "Act in good faith" means to act consney for Health Care and Living Will) is based on Minnesota Statutes Chapter 145C.16. The following are useful excerpts from the Minnesota Statutes relating to the Health Care Directive (Power of Attor (Power of Attorney for Health Care and Living Will); (2) Minnesota Health Care Directive (Power of Attorney for Health Care and Living Will) Form. This Minnesota Health Care Directive (Power of AttorInformation and Instructions Minnesota Health Care Directive (Power of Attorney for Health Care & Living Will) This package contains (1) Information and Instruction for Minnesota Health Care Directive Minnesota