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Minnesota of your medical record at your physician's office and at the hospital, home care agency, hospice, or nursing facility where you receive your care. -8- x). Give signed copies to 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 s Two) Print Name: ___________________________________ Address: ______________________________________ REMINDER: Keep this document with your personal papers in a safe place (not in a safe deposit boabove in (A), I must initial this box: [______________] I certify that the information in (i) through (iv) is true and correct. -7- _____________________________________________ (Signature of Witnest named as a health 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 me) acknowledged his/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 no ___________________________________ Address: ______________________________________ Witness Two: (i) In my presence on ________________________ (date), ___________________________________________(na, I must initial this box: [______________] I certify that the information in (i) through (iv) is true and correct. _____________________________________________ (Signature of Witness One) Print Name: health 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)dged his/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 provider giving direct care to me on the day I sign this document. -6- Witness One: (i) In my presence on ________________________ (date), ___________________________________________(name) acknowle___________________ (Signature of Notary) (Notary Stamp) Option 2: Two Witnesses Two witnesses mus t sign. Only one of the two witnesses can be a health care provider or an employee of a health caret he/she authorized 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. ________________________________: Notary Public In my presence on ________________________ (date), __________________________________________________________ (name) acknowledged his/her signature on this document or acknowledged tha the person who I asked to sign this document for me) __________________________________________________________________ (Printed name of the person who I asked to sign this document for me) Option 1____________________________________________ If I cannot sign my name, I can ask someone to sign this document for me. __________________________________________________________________ (Signature ofocument willingly. ___________________________________________ My Signature Date signed: ________________________________ Date of birth: _______________________________ Address: ______________________ 1) OR witnessed by two witnesses (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 d______________________________________________________________ PART III: MAKING THE DOCUMENT LEGAL -5- This document must be signed by me. It also must either be verified by a notary public (Option_________ Any other things: _____________________________________________________________________________ _____________________________________________________________________________ _______________at happens to my body when I die (cremation, burial): _____________________________________________________________________________ ____________________________________________________________________s of my body when I die: _____________________________________________________________________________ _____________________________________________________________________________ My wishes about wh about dying: _____________________________________________________________________________ _____________________________________________________________________________ My wishes about donating part_______________________________________________________________________ _____________________________________________________________________________ Where I would like to die and other wishes I have_______________________________________________________________ _____________________________________________________________________________ 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: -4- Who I would like to be my doctor: ______________pain. This is how I 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 _______________________________________________________ If I were completely dependent on others for my care and unable to decide or speak for myself, I would want: ____________________________________________ If I were permanently unconscious and unable to decide or speak for myself, I would want: _____________________________________________________________________________ ______________________d unable to decide or speak for myself, I would want: _____________________________________________________________________________ ____________________________________________________________________for myself, I would want: _____________________________________________________________________________ _____________________________________________________________________________ If I were dying anin these situations: (Note: 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 stopped heart, surgeries, 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 mprove my medical condition 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 ___________________________ 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) -3- Many medical treatments may be used to try to it how my medical condition might affect my family: ____________________ _____________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ My thoughts abou___________________________________________________________ _____________________________________________________________________________ My beliefs about when life would be no longer worth living: _______________ _____________________________________________________________________________ My spiritual or religious beliefs and traditions: _______________________________________ _____________________________________________________________________ My fears about my health care: ____________________________________________________ ________________________________________________________________health care: My goals for my health care: _____________________________________________________ _____________________________________________________________________________ _______________________________ THESE ARE MY BELIEFS 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 ___________________________________________ -2- _____________________________________________________________________________ ________________________________________________________________________ll 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 it here: __________________________________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, and eyes, when I die. (2) To decide what wi___________________________________________ My health care agent is NOT automatically given the powers listed below in (1) and (2). If I WANT my agent to have any of the powers in (1) and (2), I must hat here: _____________________________________________________________________________ _____________________________________________________________________________ __________________________________ 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 power in (A) through (D), I MUST say tse 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 and have the same rights that I wouldtment, 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 intrusive mental health treatment. (B) Chooam 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, or withdraw consent to any care, treaw 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 act in my best interest. Whenever I 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 (D). My health care agent must folloth care agent: __________________________________________ _____________________________________________________________________________ -1- THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO DO tionship of my alternate health care agent to me: __________________________________ Telephone number of my alternate health care agent: __________________________________ Address of my alternate healAPPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my health care agent is not reasonably available, I trust and appoint __________________________________________ to be my health care agent instead. Rela__________________________ Address of my health care agent: __________________________________________________ _____________________________________________________________________________ (OPTIONAL) ons for me. This person is called my health care agent. Relationship of my health care agent to me: __________________________________________ Telephone number of my health care agent: _______________ your agent and give your agent a copy. When I am unable to decide or speak for myself, I trust and appoint _________________________________________________________________ to make health care decisican change my agent or alternate agent at any time and 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 withterest if I have not made my health care wishes known. 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 for myself. My health care agent must make health care decisions for me based on instructions I provide in this document, if any, the wishes I have made known to him or her, or must act in my best in_______________________________________, understand this document allows me to name another person (called the health care agent) to make health care decisions for me if I am unable to decide or speaksed with a tax professional. [_] The purchase and use of these forms is subject to the Discla imers and Terms of Use found at findlegalforms.com -5- Health Care Directive I, ________________________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 should be discusorms 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 make sure 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 to state. These fon of the principal's registered domestic partnership. [_] 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 a health care power of attorney is revoked by the commencement of proceedings for dissolution, annulment, or termination of the principal's -4- marriage or commencement of proceedings for terminatie agent. Unless the principal has otherwise specified in the health care directive, the appointment by the principal of the principal's spouse or registered domestic partner as health care agent under extent the subsequent instrument is inconsistent with any prior instrument. Subd. 2. Effect of dissolution or annulment of marriage or termination of domestic partnership on appointment of health carent to revoke the health care directive in whole or in part in the presence of two witnesses who do not have to be present at the same time; or (4) executing a subsequent health care directive, to thehole or in part; (2) executing a statement, in writing and dated, expressing the principal's intent to revoke the health care directive in whole or in part; (3) verbally expressing the principal's inting the health care directive instrument or directing another in the presence of the principal to destroy the health care directive instrument, with the intent to revoke the health care directive in wth the capacity to do so may revoke a health care directive in whole or in part at any time by doing any of the following: (1) canceling, defacing, obliterating, burning, tearing, or otherwise destroyn- making capacity; or if other conditions for effectiveness otherwise specified by the principal have been met. 145C.09 Revocation of health care directive. Subdivision 1. Revocation. A principal wi the principal have been met. A health care directive is not effective for a health care decision when the principal, in the determination of the attending physician of the principal, recovers decisiopal, in the determination of the attending physician of the principal, lacks decision- making capacity to make the health care decision; or if other conditions for effectiveness otherwise specified byare to the principal. 145C.06 When effective. A health care directive is effective for a health care decision when: (1) it meets the requirements of section 145C.03, subdivision 1; and (2) the princie of a health care provider providing direct care to the principal on the date of execution. A person notarizing a health care directive may be an employee of a health care provider providing direct c the health care power of attorney. -3- (b) At least one witness to the execution of the health care directive must not be a health care provider providing direct care to the principal or an employe) A health care agent or alternate health care agent appointed in 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 date of execution of the health care directive or on the date the health care agent must make decisions for the principal. Subd. 3. Individuals ineligible to act as witnesses or notary public. (an the date of execution of the health care directive or on the date the health care agent must make decisions for the principal; or (2) an employee of a health care provider attending the principal onpal by blood, marriage, registered domestic partnership, or adoption, or unless the principal has otherwise specified in the health care directive: (1) a health care provider attending the principal oaking capacity is not eligible to act as the health care agent. (b) The following individuals are not eligible to act as the health care agent, unless the individual appointed is related to the princiuals ineligible to act as health care agent. (a) An individual appointed by the principal under section 145C.05, subdivision 2, paragraph (b), to make the determination of the principal's decision- mbehalf of the principal, either by a notary public or by witnesses as provided under this chapter; and (6) include a health care instruction, a health care power of attorney, or both. Subd. 2. Individther person authorized by the principal to sign on behalf of the principal; (5) contain verification of the principal's signature or the signature of the person authorized by the principal to sign on care directive (1) be in writing; (2) be dated; (3) state the principal's name; (4) be executed by a principal with capacity to do so with the signature of the principal or with the signature of ano decision-making capacity, unless otherwise specified in the health care directive. -2- 145C.03 Requirements. Subdivision 1. must: Legal sufficiency. To be legally sufficient in this state, a healthinclude a health care power of attorney to appoint a health care agent to make health care decisions for the principal when the principal, in the judgment of the principal's attending physician, lacksare directive may include one or more health care instructions to direct health care providers, others assisting with health care, family members, and a health care agent. A health care directive may in a timely manner considering the urgency of the principal's health care needs. 145C.02 Health care directive. A principal with the capacity to do so may execute a health care directive. A health c. "Principal" means an individual age 18 or older who has executed a health care directive. Subd. 9. Reasonably available. "Reasonably available" means able to be contacted and willing and able to act.755. Subd. 7a. Health care instruction. "Health care instruction" means a written statement of the principal's values, preferences, guidelines, or directions regarding health care. Subd. 8. Principalto 144.58, a nursing home licensed to serve adults under section 144A.02, a home care provider licensed under sections 144A.43 to 144A.47, or a hospice provider licensed under sections 144A.75 to 144Aproviders, including health maintenance organizations licensed under chapter 62D. Subd. 7. Health care facility. "Health care facility" means a hospital or other entity licensed under sections 144.50 y, organization, or corporation licensed, certified, or otherwise authorized or permitted by the laws of this state to administer health care directly or through an arrangement with other health care ey, or both; or a durable power of attorney for health care executed under this chapter before August 1, 1998. Subd. 6. Health care provider. "Health care provider" means a person, health care facilit Subd. 5a. Health care directive. "Health care directive" means a written instrument that complies with section 145C.03 and includes one or more health care instructions, a health care power of attornns on these matters relate to the health care needs of the person. Subd. 5. Health care decision. "Health care decision" means the consent, refusal of consent, or withdrawal of consent to health care.5 prohibiting assisted suicide. "Health care" also includes the establishment of a person's abode -1- within or without the state and personal security safeguards for a person, to the extent decisioealth care" includes the provision of nutrition or hydration parenterally or through intubation but does not include any treatment, service, or procedure that violates the provisions of section 609.21decisions for the principal. Subd. 4. Health care. "Health care" means any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a person's physical or mental condition. "Hre agent" may also be referred to as "agent." Subd. 3. Health care power of attorney. "Health care power of attorney" means an instrument appointing one or more health care agents to make health care e agent. "Health care agent" means an individual age 18 or older who is appointed by a principal in a health care power of attorney to make health care decisions on behalf of the principal. "Health casion- making capacity" means the ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. Subd. 2. Health car health care provider, or any other person is not acting in good faith if the person violates the provisions of section 609.215 prohibiting assisted suicide. Subd. 1b. Decision- making capacity. "Decinsidering the principal's overall general health condition and prognosis and the principal's personal values to the extent known. Notwithstanding any instruction of the principal, a health care agent,n or revocation of the information expressed. If these sources of information do not provide adequate guidance to the actor, "act in good faith" means acting in the best interests of the principal, cogarding intrusive mental health treatment executed under section 253B.03, subdivision 6d, or information otherwise made known by the principal, unless the actor has actual knowledge of the modificatioSubd. 1a. Act in good faith. "Act in good faith" means to act consistently with a legally sufficient health care directive of the principal, a living will executed under chapter 145B, a declaration reating to the Health Care Directive (Power of Attorney for Health Care and Living Will) Form. 145C.01 Definitions. Subdivision 1. Applicability. The definitions in this section apply to this chapter. ttorney for Health Care Form. This Minnesota Power of Attorney for Health Care is based in part on Minnesota Statutes Chapter 145C.16. The following are useful excerpts from the Minnesota Statutes relInformation and Instructions Minnesota Power of Attorney for Health Care This package contains (1) Information and Instruction for Minnesota Power of Attorney for Health Care; (2) Minnesota Power of A Minnesota