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Vermont ______________________ Date: _________________________________________ Address: ______________________________________ Print Name: ____________________________________ 3 care home): I declare that I have personally explained the nature and effect of this durable power of attorney to the principal and that the principal understands the same. Signature: __________________________________ Statement of ombudsman, hospital representative or other authorized person (to be signed only if the principal is in or is being admitted to a hospital, nursing home or residential_____ 2 Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ___________________ he or she is aware of the nature of the document and is signing it freely and voluntarily. _____________________________________________ (Witness Signature) Print Name: _________________________________ Signature I declare that the principal appears to be of sound mind and free from duress at the time the durable power of attorney for health care is signed and that the principal has affirmed that___________________________________________________ In witness whereof, I have hereunto signed my name this ________. day of ______________, 20 ____ . ________________________________________________stitutions will have signed copies: _______________________________________________________________________ _______________________________________________________________________ ____________________nt. I have read and understand the information contained in the disclosure statement. The original of this document will be kept at ___________________________________ and the following persons and in____________________________________ (address and telephone numbers) as alternate agent. I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this documeevent the person I appoint above is unable, unwilling or unavailable to act as my health care agent, I hereby appoint __________________________________________. (name of Agent) of ___________________ecline all other treatment the primary purpose of which is to prolong my life. I want my life sustained by any reasonable medical measures, regardless of my condition. ____________ (initial) In the le prospect of regaining the ability to think and act for myself, I want care directed to my comfort and dignity and also want artificial nutrition and hydration if needed, but authorize my agent to dine all treatment (including artificial nutrition and hydration) the primary purpose of which is to prolong my life. 1 ____________ (initial) If I suffer a condition from which there is no reasonabI suffer a condition from which there is no reasonable prospect of regaining my ability to think and act for myself, I want only care directed to my comfort and dignity, and authorize my agent to decl AGREE WITH ONE OF THESE STATEMENTS, YOU MAY IINITIAL THE STATEMENT APPROPRIATE STATEMENT IN THE SPACE PROVIDED (you should delete or cross-out the inapplicable statements): ____________ (initial) If T IS OF PARTICULAR IMPORTANCE. For your convenience in dealing with that subject, some general statements concerning the withholding or removal of life-sustaining treatment are set forth below. IF YOU____________________________________________ _______________________________________________________________________ (attach additional pages as necessary) (b) THE SUBJECT OF LIFE-SUSTAINING TREATMENto you for any other reason. _______________________________________________________________________ _______________________________________________________________________ ___________________________ions whether to continue or discontinue artificial nutrition and hydration; or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs or unacceptable AND LIMITATIONS REGARDING HEALTH CARE DECISIONS. Here you may include any specific desires or limitations you deem appropriate, such as when or what life-sustaining measures should be withheld; directise in this document. This durable power of attorney for health care shall take effect in the event I become unable to make my own health care decisions. (a) STATEMENT OF DESIRES, SPECIAL PROVISIONS, ___________________. (name of Agent) of _______________________________ (address and telephone numbers)as my agent to make any and all health care decisions for me, except to the extent I state otherwho have a claim against you. 2 Durable Power Of Attorney For Health Care I , ________________________________________________________ (name of Principal) hereby appoint _____________________________ have designated as your agent; your health or residential care provider or one of their employees; your spouse; your lawful heirs or beneficiaries named in your will or a deed; creditors or persons wED IN THE PRESENCE OF TWO (2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES: · · · · · the person youble or ineligible to act as your agent. Any alternate agent you designate will have the same authority to make health care decisions for you. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNy not be changed or modified. If you want to make changes in the document you must make an entirely new one. You may wish to designate an alternate agent in the event that your agent is unwilling, unaiven to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care provider orally or in writing. This document mas made in good faith on your behalf. Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be gour physician and give each a signed copy. You should indicate on the document itself the people and 1 institutions who will have signed copies. Your agent will not be liable for health care decision not permit a person to do both at the same time. You should inform the person you appoint that you want him or her to be your health care agent. You should discuss this document with your agent and yncy, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your agent or as your health or residential care provider; the law doespoint as agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your physician, or an employee of a home health age. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. The person you ap nature and range of decisions which may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions about your health care as you would have had. It is important that you discuss this document with your physician or other health care providers before you sign it to make sure that you understand theete your statement. Your agent will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent will have the same authority to make decisionssure you receive. Your agent's authority will begin when your doctor certifies that you lack the capacity to make health care decisions. You may attach additional pages if you need more space to complsent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. You may state in this document any treatment you do not desire or treatment you want to be e or treat your physical or mental condition. Your agent therefore can have the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw conent the authority to make any and all health care decisions for you when you are no longer capable of making them yourself. "Health care" means any treatment, service or procedure to maintain, diagnosE THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agrms is subject to the Disclaimers and Terms of Use found at findlegalforms.com 3 Vermont Durable Power Of Attorney for Health Care INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARways recommended when dealing with 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 foe 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 from a local attorney is alfic 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. Thesf responsible for the principal's care of the revocation. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any speciovided 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 attending physician and staff attorney for health care; or (3) by the divorce of the principal and spouse, where the spouse is the principal's agent. (b) A principal's health or residential care provider who is informed of or pr or a health or residential care provider orally, or in writing, or by any other act evidencing a specific intent to revoke the power; (2) by execution by the principal of a subsequent durable power oresence and at the principal's express direction. 14 V.S.A. § 3457. (Revocation) (a) A durable power of attorney for health care shall be revoked: 2 (1) by notification by the principal to the agently and voluntarily. If the principal is physically unable to sign, the durable power of attorney for health care may be signed by the principal's name written by some other person in the principal's pind and free from duress at the time the durable power of attorney for health care was signed and that the principal affirmed that he or she was aware of the nature of the documents and signed it freece or by operation of law or any other person who has, at the time of execution, any claims against the estate of the principal. The witnesses shall affirm that the principal appeared to be of sound movider's employee, the principal's spouse, heir, or reciprocal beneficiary, a person entitled to any part of the estate of the principal upon the death of the principal under a will or deed in existenhe principal in the presence of at least two or more subscribing witnesses, neither of whom shall, at the time of execution, be the agent, the principal's health or residential care provider or the prelative of the principal who is an employee of the principal's residential care provider. 14 V.S.A. § 3456. (Execution and witnesses) The durable power of attorney for health care shall be signed by ts: (1) the principal'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 residential care provider; or (4) a nonrt term is defined in section 2002 of Title 18. 14 V.S.A. § 3455. (Restrictions on who can act as agent) A person may not exercise the authority of agent while serving in one of the following capacitieare. (9) "Residential care provider" means an individual or facility licensed, certified or otherwise authorized or permitted by law to operate, for profit or otherwise, a residential care home as thader the program established within the office on aging pursuant to the Older Americans Act of 1965, as amended. (8) "Principal" means an adult who has executed a durable power of attorney for health ced by law to administer health care, for profit or otherwise, in the ordinary course of business or professional practice. 1 (7) "Ombudsman" means a person appointed as a long-term care ombudsman unprocedure to maintain, diagnose or treat an individual's physical or mental condition. (6) "Health care provider" means an individual or facility licensed, certified or otherwise authorized or permittth care decisions executed in accordance with the provisions of this chapter. (5) "Health care decision" means consent, refusal to consent, or withdrawal of consent to any care, treatment, service or ficant benefits and harms of and reasonable alternatives to any proposed health care. (4) "Durable power of attorney for health care" means a document delegating to an agent the authority to make healreatment and care of the patient. (3) "Capacity to make health care decisions" means the ability to understand and appreciate the nature and consequences of a health care decision, including the signi decisions is delegated under a durable power of attorney for health care. (2) "Attending physician" means the physician, selected by or assigned to a patient, who has primary responsibility for the tor designation of an individual to make health care decisions on their behalf. 14 V.S.A. § 3452. (Definitions) As used in this chapter: (1) "Agent" means an adult to whom authority to make health careor Health Care Form. 14 V.S.A. § 3451. (Statement of purpose) The purpose of this chapter is to enable adults to retain control over their own medical care during periods of incapacity through the priHealth Care is based on Vermont Statutes Title 14 Chapter 121 Section 3466. For your convenience, we have included useful excerpts from the Vermont Statutes relating to the Durable Power Of Attorney Fcerpts from the Vermont Statutes relating to the Durable Power Of Attorney For Health Care Form; (2) Vermont Durable Power Of Attorney For Health Care Form. This Vermont Durable Power Of Attorney For Information and Instructions Vermont Durable Power Of Attorney For Health Care This package contains (1) Information and Instruction for Vermont Durable Power Of Attorney For Health Care, including ex Vermont