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Rhode Island ________ -6- ddress: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________al upon the death of the principal under a will now existing or by operation of law. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Aer declare under penalty of perjury that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the princip_________________ Address: ______________________________________ Date: ________________________________________ (AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.) I furth________ Address: ______________________________________ Date: ________________________________________ _____________________________________________ (Witness Signature) Print Name: __________________tor of a community care facility, nor an employee of an operator of a community care facility. _____________________________________________ (Witness Signature) Print Name: ___________________________o duress, fraud, or undue influence, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, an employee of a health care provider, the operaument is personally known to me to be the principal, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under n or the notary public must make the additional declaration set out following the place where the witnesses sign.) I declare under penalty of perjury that the person who signed or acknowledged this docnity care facility, (5) An employee of an operator of a community care facility. You are not required to have this document witnessed by a notary public. -5- (At least one of the qualified witnesses the following may be used as a witness: (1) A person you designate as your agent or alternate agent, (2) A health care provider, (3) An employee of a health care provider, (4) The operator of a commu ATTORNEY.) YOU ARE NOT REQUIRED TO HAVE THIS POWER OF ATTORNEY NOTARIZED STATEMENT OF WITNESSES (This document must be witnessed by two (2) qualified adult witnesses or one (1) notary public. None ofHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY 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____________________ (State) ____________________________________________ (You sign here) (THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED BY TWO (2) QUALIFIED WITNESSES WHO ARE PRESENT W AND SIGN THIS POWER OF ATTORNEY) I sign my name to this Statutory Form Durable Power of Attorney for Health Care on ____________________________ (Date) at ____________________________ (City) ________ address, and telephone number of second alternate agent.) (9) PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney for health care. DATE AND SIGNATURE OF PRINCIPAL (YOU MUST DATE, address, and telephone number of first alternate agent.) -4- (B) Second Alternate Agent: __________________________________ __________________________________________________________ (Insert name,n this document, such persons to serve in the order listed below: (A) First Alternate Agent: ____________________________________ _________________________________________________________ (Insert nametment or authority to act as my agent to make health care decisions for me, then I designate and appoint the following persons to serve as my agent to make health care decisions for me as authorized i) is not available or becomes ineligible to act as my agent to make a health care decision for me or loses the mental capacity to make health care decisions for me, or if I revoke that person's appointo 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.) If the person designated as my agent in paragraph (1u 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 unable or ineligible _______ (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 alternate agents but yo(7) DURATION. (Unless you specify a shorter period in the space below, this power of attorney will exist until it is revoked.) This durable power of attorney for health care expires on _______________ments 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 physician. 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: (a) Docunformation relating to your health, you must state the limitations in paragraph (4) ("Statement of desires, special provisions, and limitations") above.) (6) SIGNING DOCUMENTS, WAIVERS, AND RELEASES. documents that may be required in order to obtain this information. (c) Consent to the disclosure of this information. -3- (If you want to limit the authority of your agent to receive and disclose iew, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records. (b) Execute on my behalf any releases or other AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my agent has the power and authority to do all of the following: (a) Request, reviif you need more space to complete your statement. 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.) (5) INSPECTIONitial if applicable: [_____] In the event of my death, I request that my agent inform my family/next of kin of my desire to be an organ and tissue donor, if possible. (You may attach additional pages ent, services, and procedures: (b) Additional statement of desires, special provisions, and limitations regarding health care decisions: (c) Statement of desire regarding organ and tissue donation: In my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated below: (a) Statement of desires concerning life-prolonging care, treatm have broad powers to make health care decisions for you, except to the extent that there are limits provided by law.) In exercising the authority under this durable power of attorney for health care, the space below. If you want to limit in any other way the authority given your agent by this document, you should state the limits in the space below. If you do not state any limits, your agent willo make your desires known to your agent by discussing your desires with your agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them inf your desires concerning life-prolonging care, treatment, services, and procedures. You can also include a statement of your desires concerning other matters relating to your health care. You can alse decisions that are consistent with your known desires. You can, but are not required to, state your desires in the space provided below. You should consider whether you want to include a statement oow. You can indicate your desires by including a statement of your desires in the same paragraph.) -2- (4) STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. (Your agent must make health carIf you want to limit the authority of your agent to make health care decisions for you, you can state the limitations in paragraph (4) ("Statement of Desires, Special Provisions, and Limitations") belconcerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures and informing my family or next of kin of my desire, if any, to be an organ or tissue donor. (this authority, my agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires , I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In exercising ER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a durable power of attorney for health care. (3) GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this documentnt, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition. (2) CREATION OF DURABLE POWof a community care facility.) as my attorney in fact (agent) to make health care decisions for me as authorized in this document. For the purposes of this document, "health care decision" means conset: (1) your treating health care provider, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility, or (4) a nonrelative employee of an operator ___________________________ (insert name, address, and telephone number of one individual only as your agent to make health care decisions for you. None of the following may be designated as your agenxecuted copy of this document. (1) DESIGNATION OF HEALTH CARE AGENT. I, ________________________________________________ (insert your name and address) do hereby designate and appoint: _______________ care. Either keep this document where it is immediately available to your agent and alternate agents or give each of them an executed copy of this document. You may also want to give your doctor an edocument 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 decision concerning your healthuld 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 this 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. -1- You shoe 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 the right will exist until you revoke it. Your agent's power and authority ceases upon your death except to inform your family or next of kin of your desire, if any, to be an organ and tissue owner. You have thegal, (2) Acts contrary to your known desires, or (3) Where your desires are not known, does anything that is clearly contrary to your best interests. Unless you specify a specific period, this power ument any types of treatment that you do not desire. In addition, a court can take away the power of your agent to make health care decisions for you if your agent: (1) Authorizes anything that is ille to maintain, diagnose, or treat a physical or mental condition. This power is subject to any statement of your desires and any limitation that you include in this document. You may state in this docmay not be stopped or withheld if you object at the time. This document gives your agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedurng as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection at the time, and health care necessary to keep you alive your doctor not giving treatment or stopping treatment necessary to keep you alive. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so lont must act consistently with your desires as stated in this document or otherwise made known. Except as you otherwise specify in this document, this document gives your agent the power to consent to the state for this document to be legally valid and binding. This document gives the person you designate as your agent (the attorney in fact) the power to make health care decisions for you. Your ageocument which is authorized by the general laws of this state. Before executing this document, you should know these important facts: You must be at least eighteen (18) years of age and a resident of ct to the Disclaimers and Terms of Use found at findlegalforms.com -2- Statutory Form Durable Power Of Attorney For Health Care WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal der 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 forms is subjeonsulting 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 attorney whenevintended 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 used without covided "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 forms are not evocation of a durable power of attorney. § 23-4.10-2 Statutory form of durable power of attorney The statutory form of durable power of attorney is as follows (see form below): [_] These forms are prian or health care provider shall make the revocation a part of the declarant's medical record. (c) For emergency medical services personnel, the absence of reliable documentation shall constitute a rces personnel upon communication to that physician or health care provider or emergency medical services personnel by the declarant or by another who witnessed the revocation. (b) The attending physic to communicate an intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending physician or any health care provider or emergency medical servies, will, in the opinion of the attending physician, result in death. § 23-4.10-3 Revocation (a) A durable power of attorney may be revoked at any time and in any manner by which the declarant is ableor" means an individual licensed to practice medicine in this state. (11) "Terminal condition" means an incurable or irreversible condition that, without the administration of life-sustaining procedurerson" means an individual, corporation, business trust, estate, trust, partnership, association, government, governmental subdivision or agency, or any other legal entity. (10) "Physician and/or doctcedure" shall not include any medical procedure or intervention considered necessary by the attending physician or emergency service personnel to provide comfort, care, or alleviate pain. -1- (9) "Pce of a profession. (8) "Life-sustaining procedure" means any medical procedure or intervention that, when administered to a patient, will serve only to prolong the dying process. "Life-sustaining proofessions. (7) "Health-care provider" means a person who is licensed, certified, or otherwise authorized by the law of this state to administer health care in the ordinary course of business or practiel" means paid or volunteer firefighters, law enforcement officers, first responders, emergency medical technicians, or other emergency services personnel acting within the ordinary course of their pr"Director" means the director of health. (5) "Durable power of attorney" means a witnessed document executed in accordance with the requirements of § 23-4.10-2. (6) "Emergency medical services personnic, gastric, or any means other than through per oral voluntary sustenance. (3) "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient. (4) , of providing palliative care to, and withholding life-sustaining procedures from, a qualified patient. (2) "Artificial feeding" means the provision of nutrition or hydration by parenteral, nasogastrter: (1) "Advance directive protocol" means a standardized, state-wide method developed for emergency service personnel by the department of health and approved by the ambulance service advisory boardul excerpts from the Rhode Island Statutes relating to the Rhode Island Power of Attorney for Health Care Form. § 23-4.10-1.1 Definitions The following definitions govern the construction of this chapower of Attorney for Health Care Form. This Rhode Island Power of Attorney for Health Care is based on Title 23 Chapter 23-4.10 Section 23-4.10-1.1 of the Rhode Island Statutes. The following are usefInformation and Instructions Rhode Island Power of Attorney for Health Care This package contains (1) Information and Instruction for Rhode Island Power of Attorney for Health Care; (2) Rhode Island P Rhode Island