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Utah _______________ Address: ______________________________________ Phone: _______________________________________ 2 _____ Address: ______________________________________ Phone: _______________________________________ _____________________________________________ (Witness Signature) Print Name: ____________________re facility in which the declarant may be a patient at the time of signing this directive. _____________________________________________ (Witness Signature) Print Name: ______________________________intestate succession of this state or under any will or codicil of declarant; that we are not directly financially responsible for declarant's medical care; and that we are not agents of any health ca signed the above directive on behalf of the declarant; that we are not related to the declarant by blood or marriage nor are we entitled to any portion of declarant's estate according to the laws of ct the signing of this directive; that we are acquainted with the declarant and believe him to be of sound mind; that the declarant's desires are as expressed above; that neither of us is a person who________________________________________ City, County, and State of Residence We witnesses certify that each of us is 18 years of age or older and each personally witnessed the declarant sign or diretionally and mentally competent to make this directive. _____________________________________________________________________________ (Declarant's Signature) 1 _____________________________________ugh these directions may conflict with the above written directive that life-sustaining procedures be withheld or withdrawn. 6. I understand the full import of this directive and declare that I am emo_________________________________________________________ 5. I reserve the right to give current medical directions to physicians and other providers of medical services so long as I am able, even tho_________________________________________ _______________________________________________________________________ _______________________________________________________________________ ______________taining but does not include the administration of medication or the performance of any medical procedure which is intended to provide comfort care or to alleviate pain: ______________________________iders of medical services. 4. I understand that the term "life-sustaining procedure" includes artificial nutrition and hydration and any other procedures that I specify below to be considered life-suscal treatment and to accept the consequences from this refusal which shall remain in effect notwithstanding my future inability to give current medical directions to treating physicians and other prov that these procedures be withheld or withdrawn and my death be permitted to occur naturally. 3. I expressly intend this directive to be a final expression of my legal right to refuse medical or surginion of those physicians the application of life-sustaining procedures would serve only to unnaturally prolong the moment of my death and to unnaturally postpone or prolong the dying process, I direct I should have an injury, disease, or illness, which is certified in writing to be a terminal condition or persistent vegetative state by two physicians who have personally examined me, and in the opiully and voluntarily make known my desire that my life not be artificially prolonged by life-sustaining procedures except as I may otherwise provide in this directive. 2. I declare that if at any timeion 75-2-1104, UCA) This directive is made this _______________ day of ___________________, 20_____ 1. I, __________________________________________________________________, being of sound mind, willfssional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Directive To Physicians And Providers Of Medical Services (Pursuant to Sectsituation. Advice from 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 profeom time to time and from 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 rovided as to their suitability 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 frwing form or in a form substantially similar to the form approved by prior Utah law: (see form below) [_] These forms are provided "as is" and no implied or express warranties have been made or are p declarant's medical care; or (e) any agent of any health care facility in which the declarant is a patient at the time the directive is executed. (4) The directive shall be in substantially the folloed to any portion of the estate of the declarant according to the laws of intestate succession of this state or under any will or codicil of the declarant; (d) directly financially responsible for thehe witnesses may be: (a) the person who signed the directive on behalf of the declarant; (b) related to the declarant by blood or marriage; Living Will Information & Instructions ­ Page 3 (c) entitl by another person in the declarant's presence and by the declarant's expressed direction; (c) dated; and (d) signed in the presence of two or more witnesses 18 years of age or older. (3) Neither of t a directive under this part. The directive is binding upon attending physicians and all other providers of medical services. (2) The directive shall be: (a) in writing; (b) signed by the declarant org to act upon a revocation made under this part unless that person has actual knowledge of the revocation. 75-2-1104. Directive for medical services. (1) A person 18 years of age or older may executell record in the declarant's medical record the time, date, and place when notice of a written revocation was received. (3) There is no criminal or civil liability on the part of any person for failinphysician becomes binding only upon receipt by the attending physician and other providers of medical service of a written revocation under Subsection 75-2-1111 (b) or (c). The attending physician shapresence of a witness 18 years of age or older who signs and dates a written instrument confirming that the expression of intent was made. (2) Any oral revocation not otherwise known to the attending ective signed and dated by the declarant or by a person signing on behalf of the declarant or acting at the direction of the declarant; (c) oral expression of an intent to revoke the directive in the ions or a change of mind, and by: (a) being obliterated, burned, torn, or otherwise destroyed or defaced in any manner indicating an intention to effect revocation; (b) a written revocation of the dirbe revoked at any time by the declarant if the declarant has signed it personally, or by the person or persons who signed a directive on behalf of a declarant, based on changed circumstances or conditical judgment produce death, and where the application of life sustaining procedures serve only to postpone the moment of death of the person. 75-2-1111. Revocation of directive. (1) A directive may tenance organizations. (10) "Terminal condition" means a condition caused by injury, disease, or illness, which regardless of the application of life sustaining procedures, would within reasonable meds, skilled nursing facilities, intermediate care facilities, intermediate care facilities for the mentally retarded, residential health care facilities, and facilities owned or operated by health main (9) "Provider of medical services" includes all persons licensed to provide medical services and all health care facilities, including hospitals, psychiatric hospitals, home health agencies, hospiceficant cognitive function as diagnosed by two physicians, one of whom shall be the attending physician, in accordance with reasonable medical judgment. Living Will Information & Instructions ­ Page 2ctions are present and the person totally lacks higher cortical and cognitive function but maintains vegetative brain stem processes for which there exists no reasonable expectation of regaining signi any medical procedure which is intended to provide comfort care or to alleviate pain. (8) "Persistent vegetative state" means a state of severe mental impairment, in which only involuntary bodily fun declarant elects in the declaration to exclude artificially administered nutrition and hydration. (b) Life sustaining procedure does not include the administration of medication or the performance of means: (i) any medical procedure or intervention which would in the judgment of the attending physician serve only to prolong the dying process; and (ii) artificial nutrition and hydration unless theent voluntarily executed by or on behalf of a person in accordance with the requirements of this part. (6) "In writing" means any printed or hand written directive. (7) (a) "Life sustaining procedure"clarant" means a person 18 years of age or older who has signed or directed the signing of any directive, or for whom a directive has been signed under this part. (5) "Directive" means a written documng, such as spoon or bottle feeding. (3) "Attending physician" means the physician selected by or assigned to a person, who has primary responsibility for the treatment and care of the person. (4) "Deis not required to chew or swallow voluntarily, including nasogastric tubes, gastrostomies, jejunostomies, and intravenous infusions. Artificial nutrition and hydration does not include assisted feedid to act on behalf of a provider of medical services. (2) "Artificial nutrition and hydration" means supplying food and water through a conduit such as a tube or intravenous line, where the recipient ve included useful excerpts from the Utah Statutes relating to Living Wills. 75-2-1103. Definitions. As used in this part: (1) "Agent" means any director, officer, employee, or other person authorizeh Directive To Physicians And Providers Of Medical Services (Living Will). This Utah Living Will is based on Title 75 Chapter 2 Section 1103 et. Seq. of the Utah Statutes . For your convenience, we ha_________ Information and Instructions Utah Living Will This package contains (1) Information and Instruction for Utah Directive To Physicians And Providers Of Medical Services (Living Will); (2) Utahe was acting under no constraint or undue influence whatsoever. My commission expires: ____________________________ ____________________________________ Notary Public Residing at: ____________________________________, who duly acknowledged to me that he has read and fully understands the foregoing power of attorney, executed the same of his own volition and for the purposes set forth, and that l State of ___________________________ ) ) ss. County of __________________________ ) On the ________ day of ________, ________, personally appeared before me ______________________________________on rendering me unable to give current directions to attending physicia ns and other providers of medical services as to my care and treatment. _________________________________ Signature of Principaably be the same as I would give if able to do so. This power of attorney shall be and remain in effect from the time my attending physician certifies that I have incurred a physical or mental conditiith confidence in the belief that this person's familiarity with my desires, beliefs, and attitudes will result in directions to attending physicians and providers of medical services which would probncur an injury, disease, or illness which renders me unable to give current directions to attending physicians and other providers of medical services. I have carefully selected my above-named agent without substitution, with lawful authority to execute a directive on my behalf under Section 75-2-1105, governing the care and treatment to be administered to or withheld from me at any time after I iay of ________, ________, being of sound mind, willfully and voluntarily appoint ______________________________________ of ________________________________________ as my agent and attorney-in- fact, windlegalforms.com -2- Special Power of Attorney for Health Care I, ________________________________________________________________________, of _____________________________________, this ________ dny possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at f signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Ar 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 consulting with an attorney first. Before using ores 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 intended and are not a substitute for legal and/oerson for failing to act upon a revocation made under this part unless that person has actual knowledge of the revocation. -1- [_] These forms are provided "as is" and no implied or express warranting physician shall record in the declarant's medical record the time, date, and place when notice of a written revocation was received. (3) There is no criminal or civil liability on the part of any po the attending physician becomes binding only upon receipt by the attending physician and other providers of medical service of a written revocation under Subsection 75-2-1111 (b) or (c). The attendiirective in the presence of a witness 18 years of age or older who signs and dates a written instrument confirming that the expression of intent was made. (2) Any oral revocation not otherwise known tation of the directive signed and dated by the declarant or by a person signing on behalf of the declarant or acting at the direction of the declarant; (c) oral expression of an intent to revoke the dtances or conditions or a change of mind, and by: (a) being obliterated, burned, torn, or otherwise destroyed or defaced in any manner indicating an intention to effect revocation; (b) a written revocA directive may be revoked at any time by the declarant if the declarant has signed it personally, or by the person or persons who signed a directive on behalf of a declarant, based on changed circumsroved by prior Utah law: (2) A directive executed by an attorney-in- fact appointed under this section takes precedence over all previously signed directives. 75-2-1111. Revocation of directive. (1) s him unable to make a directive, by executing a special power of attorney before a notary public, which shall be in substantially the following form or in a form substantially similar to the form appmay designate any other person 18 years of age or older to execute a directive under Section 75-2-1105 on behalf of the principal after the principal incurs an injury, disease, or illness which render are useful excerpts from the Utah Statutes relating to the Utah Power of Attorney for Health Care Form. 75-2-1106. Special power of attorney. (1) A person 18 years of age or older, the "principal," or Health Care ; (2) Utah Power of Attorney for Health Care Form. This Utah Power of Attorney for Health Care is based on Title 75 Chapter 02 Section 75-2-1106 et. Seq. of the Utah Code. The followingers and Terms of Use found at findlegalforms.com Information and Instructions Utah Power of Attorney for Health Care This package contains (1) Information and Instruction for Utah Power of Attorney fwith estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaiming point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing al 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 forms should only be a startal Services (Living Will). [_] 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 purpose or as to their legse forms are also sometimes known as an Advance Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Directive To Physicians And Providers Of MedicUtah Advance Health Care Directive This package contains both a Utah Power of Attorney for Health Care and a Utah Directive To Physicians And Providers Of Medical Services (Living Will). Together the Utah