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Minnesota oxy 6 __________________________________ Address: ______________________________________ Reminder: · · Keep the signed original with your personal papers. Give signed copies to your doctors, family, and pr___ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: _ proxy by the living will, and to the best of my knowledge, I am not entitled to any part of the estate of the Declarant under a will or by operation of law. __________________________________________ration of law, and neither of whom is your proxy.) I certify that the Declarant voluntarily signed this living will in my presence and that the Declarant is personally known to me. I am not named as a_____ ___________________________________ NOTARY PUBLIC 5 OR (Sign and date here in the presence of two adult witnesses, neither of whom is entitled to any part of your estate under a will or by ope. _________________________________ ) ) ) Subscribed, sworn to, and acknowledged before me by ________________________________ (name of Declarant) on this ___________ day of ________________, _______________________________ (Pursuant to §145B.03 (2)(a): A living will is effective only if it is signed by the Declarant and two witnesses or a notary public Living will.) STATE OF MINNESOTA COUNTY OF ther form to donate some or all of my organs when I die. [________] I do not wish to become an organ donor upon my death. DATE: ____________________________________________ SIGNED: ___________________ for donation. Therefore, it is in my best interests to inform my next of kin about my decision ahead of time and ask them to honor my request. I (have) (have not) agreed in another document or on ano_____________________________________________________ _________________________________________________________________________ I understand that, upon my death, my next of kin may be asked permissionicially on a breathing machine, (i.e., artificial ventilation), so that my organs can be removed. Limitations or special wishes: (If any) _________________________________________ ____________________s your wish: [________] In the event of my death, I would like to donate my organs. I understand that to become an organ donor, I must be declared brain dead. My organ function may be maintained artifto the proxy or my health care provider. 4 (9) Organ Donation After Death. (If you wish, you may indicate whether you want to be an organ donor upon your death.) Initial the statement which expressenship: (If any) ________________________________ I understand that I have the right to revoke the appointment of the persons named above to act on my behalf at any time by communicating that decision horize the following person to do so: Name: ____________________________________________ Address: __________________________________________ Phone Number: _____________________________________ Relatioip: (If any) ________________________________ If the person I have named above refuses or is unable or unavailable to act on my behalf, or if I revoke that person's authority to act as my proxy, I autrdian or conservator of my person. Name: ____________________________________________ Address: __________________________________________ Phone Number: _____________________________________ Relationsh proxy has full power and authority to make health care decisions for me. If a guardian or conservator of the person is to be appointed for me, I nominate my proxy named in this document to act as guaructions, I designate the following person(s) to act on my behalf consistently with my instructions, if any, as stated in this document. Unless I write instructions that limit my proxy's authority, my You may also name a proxy without including specific instructions regarding your care. If you name a proxy, you should discuss your wishes with that person.) If I become unable to communicate my inst_____________________________________________________________________ (8) Proxy Designation. (If you wish, you may name someone to see that your wishes are carried out, but you do not have to do this.___________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ________eligious beliefs, philosophy, or other personal values that you feel are important. You may also state preferences concerning the location of your care.) 3 ___________________________________________________________________________ _____________________________________________________________________________ (7) Thoughts I feel are relevant to my instructions. (You may, but need not, give your r_____________________________________________________________________________ _____________________________________________________________________________ ____________________________________________dministered sustenance should I have a terminal condition (you may indicate whether you wish to receive food and fluids given to you in some other way than by mouth if you have a terminal condition): if I reject artificially administered sustenance, then I may die of dehydration or malnutrition rather than from my illness or injury. The following are my feelings and wishes regarding artificially a______________________ _____________________________________________________________________________ _____________________________________________________________________________ (6) I recognize that treatment that you do not want if you have a terminal condition): _____________________________________________________________________________ ____________________________________________________________________________ (5) I particularly do not want the following kinds of life-sustaining treatment if I am diagnosed to have a terminal condition (you may list the specific types of life-sustaining_________________________________________________________________ _____________________________________________________________________________ ________________________________________________________ may list the specific types of life-sustaining treatment that you do want if you have a terminal condition): _____________________________________________________________________________ _______________________________________________________________________________ (4) I particularly want to have the following kinds of life-sustaining treatment if I am diagnosed to have a terminal condition (you_____________________________ _____________________________________________________________________________ _____________________________________________________________________________ 2 ________________________________________ (3) I particularly do not want the following (you may list specific treatment you do not want in certain circumstances): __________________________________________________________________________________________________________________________ _____________________________________________________________________________ _______________________________________________ave all appropriate health care that will help in the following ways (you may give instructions for care you do want): _____________________________________________________________________________ __________________ _____________________________________________________________________________ _____________________________________________________________________________ (2) I particularly want to hte the circumstances under which this living will applies): _____________________________________________________________________________ ______________________________________________________________edical and health care decisions for myself as long as I am able to do so and to revoke this living will at any time. (1) The following are my feelings and wishes regarding my health care (you may stahealth care providers are legally bound to act consistently with my wishes, within the limits of reasonable medical practice and other applicable law. I also understand that I have the right to make millfully and voluntarily make this statement as a directive to be followed if I am in a terminal condition and become unable to participate in decisions regarding my health care. I understand that my or a notary public. 1 TO MY FAMILY, DOCTORS, AND ALL THOSE CONCERNED WITH MY CARE: I, ____________________________________, born on ____________________ (birthdate), being an adult of sound mind, wou do not understand, you should ask for professional help to have it explained to you. Pursuant to §145B.03 (2)(a): A living will is effective only if it is signed by the Declarant and two witnesses medical records and to consent to their disclosure for purposes related to your health care or insurance unless you limit this right in this document. (e) If there is anything in this document that y continues to reflect your preferences. You may amend or revoke the living will at any time by notifying your health care providers. (d) Your named proxy has the same right as you have to examine your instructions or tell you that they are unwilling to do so. (c) This document will remain valid and in effect until and unless you amend or revoke it. Review this document periodically to make sure itr wishes. If the proxy does not know your wishes, the proxy has the duty to act in your best interests. If you do not name a proxy, your health care providers have a duty to act consistently with yourtate where you want or do not want to receive any treatment. (b) If you name a proxy in this document and that person agrees to serve as your proxy, that person has a duty to act consistently with youn you are in a terminal condition and cannot do so. This document may include what kind of treatment you want or do not want and under what circumstances you want these decisions to be made. You may snt, you should know these important facts: (a) This document gives your health care providers or your designated proxy the power and guidance to make health care decisions according to your wishes whechase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Health Care Living Will Notice: This is an important legal document. Before signing this documeom 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 tax professional. [_] The purfrom 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 particular situation. Advice frsuitability 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 n of the former spouse as a proxy to make health care decisions for the Declarant. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their ressly provides otherwise, if after executing a living will the Information & Instructions ­ Page 3 Declarant's marriage is dissolved or annulled, the dissolution or annulment revokes any designatio provider shall note the revocation as part of the Declarant's medical record. Subd. 2. Effect of marriage dissolution or annulment on designation of proxy. Unless a living will under this chapter exprant's physical or mental condition. A revocation is effective when the Declarant communicates it to the attending physician or other health care provider. The attending physician or other health careion 525.544. 145B.09 Revocation. Subdivision 1. General. A living will under this chapter may be revoked in whole or in part at any time and in any manner by the Declarant, without regard to the Declal." Subd. 3. Guardian or conservator. Except as otherwise provided in the living will, designation of a proxy is considered a nomination of a guardian or conservator of the person for purposes of sectlaration on the document: "I certify that the Declarant voluntarily signed this living will in my presence and that the Declarant is personally known to me. I am not named as a proxy by the living wilDeclarant under a will then existing or by operation of law. Neither of the witnesses nor the notary may be named as a proxy in the living will. Each witness shall substantially make the following decly unable to sign the document, one of the witnesses shall sign the document at the Declarant's direction. (d) Neither of the witnesses can be someone who is entitled to any part of the estate of the he withholding or withdrawing of artificially administered nutrition or hydration. (c) The living will may be communicated to and then transcribed by one of the witnesses. If the Declarant is physicalion artificially shall be made pursuant to section 145B.13. However, the mere existence of a living will or appointment of a proxy does not, by itself, create a presumption that the Declarant wanted tutrition and hydration, the living will shall be enforceable as to all other preferences or instructions regarding health care, and a decision to administer, withhold, or withdraw nutrition and hydratt if the Declarant is unable to make health care decisions and the living will becomes operative. If the living will does not state the Declarant's preferences regarding artificial administration of ntion of nutrition and hydration; or (2) that the Declarant wishes the proxy, if any, to make decisions regarding the administering of artificially administered nutrition and hydration for the Declaranthe Declarant and two witnesses or a notary public. (b) A living will must state: (1) the Declarant's preferences regarding whether the Declarant wishes to receive or not receive artificial administralth care decisions on behalf of the Declarant, or both. Information & Instructions ­ Page 2 Subd. 2. Requirements for executing a living will. (a) A living will is effective only if it is signed by nsent to or refusal of any health care, treatment, service, procedure, or placement. A living will may include preferences or instructions regarding health care, the designation of a proxy to make heaing will. Subdivision 1. Scope. A competent adult may make a living will of preferences or instructions regarding health care. These preferences or instructions may include, but are not limited to, cobd. 8. Terminal condition. "Terminal condition" means an incurable or irreversible condition for which the administration of medical treatment will serve only to prolong the dying process. 145B.03 Livaws of this state to administer health care directly or through an arrangement with other health care providers. Subd. 7. HMO. "HMO" means an organization licensed under sections 62D.01 to 62D.30. Su to 144A.49. Subd. 6. Health care provider. "Health care provider" means a person, health care facility, organization, or corporation licensed, certified, or otherwise authorized or permitted by the lility" means a hospital or other entity licensed under sections 144.50 to 144.58; a nursing home licensed to serve adults under section 144A.02; or a home care provider licensed under sections 144A.43. Subd. 4. Health care decision. "Health care decision" means a decision to begin, continue, increase, limit, discontinue, or not begin any health care. Subd. 5. Health care facility. "Health care fac3. Subd. 3. Health care. "Health care" means care, treatment, services, or procedures to maintain, diagnose, or treat an individual's physical condition when the individual is in a terminal conditionng Wills. 145B.02 Definitions. Subdivision 1. Applicability. The definitions in this section apply to this chapter. Subd. 2. Living will. "Living will" means a writing made according to section 145B.0innesota Health Care Living Will is based on Minnesota Statutes Chapter 145B.02 et. Seq. For your convenience, we have included useful excerpts from the Minnesota Statutes relating to Health Care LiviInformation and Instructions Minnesota Health Care Living Will This package contains (1) Information and Instruction for Minnesota Health Care Living Will; (2) Minnesota Health Care Living Will This M Minnesota