$17.95

Add to cart

North Dakota ______________________________ (Signature of alternate agent/date) -6- o withdraw when the principal is incapable of making the principal's health care decisions, I must notify the principal's physician. ___________________________________ (Signature of agent/date) _____the principal may revoke this power of attorney at any time in any manner. If I choose to withdraw during the time the principal is competent, I must notify the principal of my decision. If I choose t health care decisions for the principal only if the principal becomes incapable. I understand that I must act in good faith in exercising my authority under this power of attorney. I understand that nt for health care decisions. I understand I have a duty to act consistently with the desires of the principal as expressed in this appointment. I understand that this document gives me authority over______________________ (Signature of Witness Two) ____________________________________ (Address) 10. ACCEPTANCE OF APPOINTMENT OF POWER OF ATTORNEY. I accept this appointment and agree to serve as ager or an employee of a health care provider giving direct care to the declarant, I must initial this box: [______]. I certify that the information in (1) through (3) is true and correct. ______________this document or acknowledged that the declarant directed the person signing this document to sign on the declarant's behalf. (2) I am at least eighteen years of age. (3) If I am a health care provide ____________________________________ (Address) Witness Two: (1) In my presence on _________ (date), ____________________________________ (name of declarant) acknowledged the declarant's signature on ct care to the declarant, I must initial this box: [______]. I certify that the information in (1) through (3) is true and correct. -5- ____________________________________ (Signature of Witness One)ted the person signing this document to sign on the declarant's behalf. (2) I am at least eighteen years of age. (3) If I am a health care provider or an employee of a health care provider giving dires One: (1) In my presence on _________ (date), ____________________________________ (name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant direc signing this document to sign on the declarant's behalf. _________________________ (Signature of Notary Public) My commission expires __________________________ , 20__. Option 2: Two Witnesses Witnes: Notary Public In my presence on __________ (date), ________________ (name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person marriage, or adoption; 4. A person entitled to inherit any part of your estate upon your death; or 5. A person who has, at the time of executing this document, any claim against your estate. Option 1oviding you with direct care. None of the following may be used as a notary or witness: 1. A person you designate as your agent or alternate agent; 2. Your spouse; 3. A person related to you by blood,t least one witness to the execution of the document must not be a health care or long-term care provider providing you with direct care or an employee of the health care or long-term care provider prument must be (1) notarized or (2) witnessed by two qualified adult witnesses. The person notarizing this document may be an employee of a health care or long-term care provider providing your care. AANY ADDITIONAL PAGES 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.) -4- NOTARY PUBLIC OR STATEMENT OF WITNESSES This doc(You sign here) (THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS NOTARIZED OR SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED o this Statutory Form Durable Power of Attorney For Health Care on _____________ (date) at _____________________ (city) ______________________ (state) ________________________________________________ te agent.) 9. 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 sign my name tAlternate Agent: _______________________________________________________ _________________________________________________________________ (Insert name, address, and telephone number of second alterna___________________________________________________ __________________________________________________________________ (Insert name, address, and telephone number of first alternate agent.) b. Second point the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below: a. First Alternate Agent: _______r loses the mental capacity to make health care decisions 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 apnot you are capable of designating another agent.) If 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 oble 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. Your agent may withdraw whether or ernate 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, above, in the event that agent is una____________________________ (Fill in this space ONLY if you want the authority of your agent to end on a specific date.) 8. DESIGNATION OF ALTERNATE AGENTS. (You are not required to designate any altsician. 7. DURATION. (Unless you specify a shorter period in the space below, this power of attorney will exist until it is revoked.) -3- This durable power of attorney for health care expires on ___: a. Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice". b. Any necessary waiver or release from liability required by a hospital or phyRELEASES. Where necessary to implement the health care decisions 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(If you want to limit the authority of your agent to receive and disclose information relating to your health, you must state the limitations in paragraph 4 above.) 6. SIGNING DOCUMENTS, WAIVERS, AND uding 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 information. ions in this document, 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, incl so pursuant to North Dakota Century Code chapter 23-06.2, the Uniform Anatomical Gift Act. 5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitattement. If you attach additional pages, you must date and sign EACH of the additional pages at the same time you date and sign this document.) If you wish to make a gift of any bodily organ you may do____________________________________________ ______________________________________________________________________________ (You may attach additional pages if you need more space to complete your staement of desires, special provisions, and limitations regarding health care decisions: ______________________________________________________________________________ _________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ b. Additional state special provisions and limitations stated below: a. Statement of desires concerning life-prolonging care, treatment, services, and procedures: _______________________________________________________re limits provided by law.) -2- In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with my desires as stated below and is subject to thhis document, you should state the limits in the space below. If you do not state any limits, your agent will have broad powers to make health care decisions for you, except to the extent that there ame other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit in any other way the authority given your agent by tn also include a statement of your desires concerning other matters relating to your health care. You can also make your desires known to your agent by discussing your desires with your agent or by sostate your desires in the space provided below. You should consider whether you want to include a statement of your desires concerning life-prolonging care, treatment, services, and procedures. You came paragraph.) 4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. (Your agent must make health care decisions that are consistent with your known desires. You can, but are not required to, the authority of your agent to make health care decisions for you, you can state the limitations in paragraph 4 below. You can indicate your desires by including a statement of your desires in the sathis document or otherwise made known to my agent, including my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures. (If you want to limitnt 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 in care. 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 exten, diagnose, or treat an individual's physical or mental condition. 2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a durable power of attorney for healthhorized in this document. For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintaire provider, an operator of a long-term care facility, or a nonrelative employee of an operator of a long-term care facility) as my attorney in fact (agent) to make health care decisions for me as autl only as your agent to make health care decisions for you. None of the following may be designated as your agent: your treating health care provider, a nonrelative employee of your treating health cado hereby designate and appoint: __________________________________________________ _______________________________________________________ (insert name, address, and telephone number of one individuaoctor an executed copy of this document. 1. DESIGNATION OF HEALTH CARE AGENT. I, __________________________________ ____________________________________________________ (insert your name and address) your health care. Either keep this document where it is immediately available to your agent and alternate agents, if any, or give each of them an executed copy of this document. You should give your dthis document that you do not understand, you should ask a lawyer to explain it to you. Your agent may need this document immediately in case of an emergency that requires a -1- decision concerning u should carefully read and follow the witnessing procedure described at the end of this form. This document will not be valid unless you comply with the witnessing procedure. If there is anything in the right to examine your medical records and to consent to their disclosure unless you limit this right in this document. This document revokes any prior durable power of attorney for health care. Yoou have the right to revoke the authority of your agent by notifying your agent or your treating doctor, hospital, or other health care provider orally or in writing of the revocation. Your agent has oes anything that is clearly contrary to your best interest. Unless you specify a specific period, this power will exist until you revoke it. Your agent's power and authority ceases upon your death. Yn take away the power of your agent to make health care decisions for you if your agent authorizes anything that is illegal; acts contrary to your known desires; or where your desires are not known, d is subject to any statement of your desires and any limitation that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court cafuse to consent to, or to withdraw consent for any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition if you are unable to do so yourself. This powerdical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. This document gives your agent authority to request, consent to, re this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive. Notwithstanding this document, you have the right to make mehe power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known. Except as you otherwise specify in this document,these important facts: You must be at least eighteen years of age for this document to be legally valid and binding. This document gives the person you designate as your agent (the attorney in fact) tney For Health Care WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document that is authorized by the general laws of this state. Before executing this document, you should know uld 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 -4- Statutory Form Durable Power Of Attorto 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 shotate. 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 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 to sdo not preclude application of any other penalties provided by law. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability forters, forges, conceals, or destroys a power of attorney or willfully alters or forges a revocation of a power of attorney is guilty of a class A misdemeanor. 3. The penalties provided in this section a withholding or withdrawal of life-sustaining procedures which hastens the death of the principal is guilty of a class C felony. 2. A person who, without authorization of the principal, willfully al Penalties. 1. A person who, without authorization of the principal, willfully alters or forges a power of attorney or willfully conceals or destroys a revocation with the intent and effect of causing form may be used if it complies with this chapter. 23-06.5-17. Statutory form of durable power of attorney. The statutory form of durable power of attorney is as follows (see form below): 23-06.5-18.ired form, by which a person may execute a durable power of attorney for health care pursuant to this chapter. It is known as "the statutory form of durable power of attorney for health care". Anotherre of such medical information. 23-06.5-16. Use of statutory form. The statutory form of durable power of attorney described in section 23-06.5-17 may be used and is the preferred form, but not a requental health, including medical and hospital records; -3- 2. Execute any releases or other documents which may be required in order to obtain such medical information; and 3. Consent to the disclosual, an agent whose authority is in effect may for the purpose of making health care decisions: 1. Request, review, and receive any information, oral or written, regarding the principal's physical or mrced spouse as the principal's agent. 23-06.5-08. Inspection and disclosure of medical information. Subject to any limitations set forth in the durable power of attorney for health care by the principding physician, and staff responsible for the principal's care of the revocation. 3. If the spouse is the principal's agent, the divorce of the principal and spouse revokes the appointment of the divoho is informed of or provided with a revocation of a durable power of attorney for health care shall immediately record the revocation in the principal's medical record and notify the agent, the attena specific intent to revoke the power; or b. By execution by the principal of a subsequent durable power of attorney for health care. 2. A principal's health care or long-term care services provider wwer of attorney for health care is revoked: a. By notification by the principal to the agent or a health care or long-term care services provider orally, or in writing, or by any other act evidencing t may withdraw by giving notice to the attending physician. The attending physician shall cause the withdrawal to be recorded in the principal's medical record. 23-06.5-07. Revocation. 1. A durable poncipal at such time as the principal becomes incapable. Until the principal becomes incapable, the agent may withdraw by giving notice to the principal. After the principal becomes incapable, the agenfective, the agent must accept the appointment in writing. Subject to the right of the agent to withdraw, the acceptance creates a duty for the agent to make health care decisions on behalf of the pri be signed by the principal's name being written by some other person in the principal's presence and at the principal's express direction. 23-06.5-06. Acceptance of appointment - Withdrawal. To be ef financially responsible for the principal's medical care, or the attending physician of the principal. If the principal is physically unable to sign, the durable power of attorney for health care maye death of the principal under a will or deed in existence or by operation of law, any other person who has, at the time of execution, any claims against the estate of the principal, a person directlyhe time of execution, the agent, the principal's spouse or heir, a person related to the principal by blood, marriage, or adoption, a person entitled to any part of the estate of the principal upon threct care to the principal or an employee of a health care or long-term care provider providing direct care to the principal on the date of execution. The notary public or any witness may not be, at ta health care or long-term care provider providing direct care to the principal. At least one witness to the execution of the document must not be a health care or long-term care provider providing dind that signature must be verified by a notary public or at least two or more subscribing witnesses who are at least eighteen years of age. A person notarizing -2- the document may be an employee of e principal who is an employee of the principal's long-term care services provider. 23-06.5-05. Execution and witnesses. The durable power of attorney for health care must be signed by the principal apal's health care provider; 2. A nonrelative of the principal who is an employee of the principal's health care provider; 3. The principal's long-term care services provider; or 4. A nonrelative of thure is first approved by court order. 23-06.5-04. Restrictions on who can act as agent. A person may not exercise the authority of agent while serving in one of the following capacities: 1. The princialth facility or state institution for a period of more than forty-five days without a mental health proceeding or other court order, or to psychosurgery, abortion, or sterilization, unless the procedable efforts to inform the principal of any proposed treatment, or of any proposal to withdraw or withhold treatment. 5. Nothing in this chapter permits an agent to consent to admission to a mental hecity to make health care decisions, as certified in writing by the principal's attending physician and filed in the principal's medical record. 4. The principal's attending physician shall make reasonin accordance with the agent's assessment of the principal's best interests. 3. Under a durable power of attorney for health care, the agent's authority is in effect only when the principal lacks capaoral beliefs, as stated orally, or as contained in the durable power of attorney for health care or in a declaration executed pursuant to chapter 23-06.4; or b. If the principal's wishes are unknown, ation with the attending physician and other health care providers, the agent shall make health care decisions: a. In accordance with the agent's knowledge of the principal's wishes and religious or mncipal in the durable power of attorney for health care, the agent has the authority to make any and all health care decisions on the principal's behalf that the principal could make. 2. After consultas executed a durable power of attorney for health care. -1- 23-06.5-03. Scope and duration of authority. 1. Subject to the provisions of this chapter and any express limitations set forth by the priiness or professional practice. 7. "Long-term care facility" or "long-term care services provider" means a long-term care facility as defined in section 50-10.1-01. 8. "Principal" means an adult who hHealth care provider" means an individual or facility licensed, certified, or otherwise authorized or permitted by law to administer health care, for profit or otherwise, in the ordinary course of busonsent to, refusal to consent to, withdrawal of consent to, or request for any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition. 6. "orney for health care" means a document delegating to an agent the authority to make health care decisions executed in accordance with the provisions of this chapter. 5. "Health care decision" means c and appreciate the nature and consequences of a health care decision, including the significant benefits and harms of and reasonable alternatives to any proposed health care. 4. "Durable power of atte physician, selected by or assigned to a patient, who has primary responsibility for the treatment and care of the patient. 3. "Capacity to make health care decisions" means the ability to understand context otherwise requires: 1. "Agent" means an adult to whom authority to make health care decisions is delegated under a durable power of attorney for health care. 2. "Attending physician" means thze, or approve mercy killing, or permit an affirmative or deliberate act or omission to end life, other than to allow the natural process of dying. 23-06.5-02. Definitions. In this chapter, unless thein control over their own medical care during periods of incapacity through the prior designation of an individual to make health care decisions on their behalf. This chapter does not condone, authoril excerpts from the North Dakota Statutes relating to the North Dakota Power of Attorney for Health Care Form. 23-06.5-01. Statement of purpose. The purpose of this chapter is to enable adults to retaower of Attorney for Health Care Form. This North Dakota Power of Attorney for Health Care is based Title 23 Chapter 23-06.5 Section 23-06.5-01 of the on North Dakota Statutes. The following are usefuInformation and Instructions North Dakota Power of Attorney for Health Care This package contains (1) Information and Instruction for North Dakota Power of Attorney for Health Care; (2) North Dakota P North Dakota