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Washington ______________________________ Address: __________________________________ __________________________________ -3- here: __________________________________ Address: __________________________________ __________________________________ Signature of witness 2: __________________________________ Print name here: ____an employee or an attending physician of the declarer or of the health care facility (if any) in which the declarer is a patient. Signature of witness 1: __________________________________ Print name stated I am not mentioned in his or her will, that I am not entitled to receive any portion of the declarer's estate by operation of law, that I have no claim against the declarer, and that I am not rer has been personally known to me and I believe to be capable of making health care decisions. In addition, I affirm that I am not related to the declarer by blood or marriage, that the declarer has_____________ ______________________________________________________________________ Social Security Number or Birthdate ________________________________________ -2- Statement of Witnesses The declaature ______________________________________________________________ Printed name:___________________________________________________________ Address:__________________________________________________treatment facility for the mentally ill, except pursuant to the provisions of Chapter 71.05 RCW; d). Sterilization. Signed at ________________________ , Washington, on __________________ (date) Signe following absent a court order: a). Therapy or other procedure given for the purpose of inducing convulsion; b). Surgery solely for the purpose of psychosurgery; c). Commitment to or placement in a 1) to serve as my guardian. My second choice (on page 1) will serve as my guardian if the first person is unable or unwilling. The above authorization to make health care decisions does not include thave executed or may execute in the future. In the event that a proceeding is initiated to appoint a guardian of my person under RCW 11.88, I nominate the person designated as my first choice (on page erest in making health care decisions. The existence of this Durable Power of Attorney for Health Care shall have no effect upon the validity of any other Power of Attorney for other purposes that I here, and to receive and consent to the release of medical information. When the Health Care Agent does not have any stated desires or instructions from me to follow, he or she shall act in my best int instructions for the provision, withholding, or withdrawing of life-sustaining treatment, which are contained in any Health Care Directive or other form of "living will" I may have executed or elsewh not limited to consent to initiate, continue, discontinue, withdraw withhold or forgo medical care and treatment including artificially supplied nutrition and hydration, following and interpreting myd to making decisions about my health care on my behalf. These powers shall include the power to give informed consent for health care treatment when I am not capable of doing so. This includes but is(Name) (Address) _______________________________________________________________________ (City) (State) (Zip) (Phone) -1- The powers of my attorney- in- fact under this Power of Attorney are limitevent that both ________________________ and _________________________ are unable or unwilling to serve, I grant these powers to _______________________________________________________________________ _______________________________________________________________________ (Name) (Address) _______________________________________________________________________ (City) (State) (Zip) (Phone) In the eplan, stop, and refuse treatment on my behalf with the treating physicians and health personnel. In the event that __________________________ is unable or unwilling to serve, I grant these powers to orney for Health Care recognized in RCW 11.94.010, and authorize her or him to consult with my physicians about the possibility of my regaining the capacity to make treatment decisions and to accept, ess) _______________________________________________________________________ (City) (State) (Zip) (Phone) as my attorney- in- fact (Health Care Agent) by granting him or her the Durable Power of Attr her designee determines that I am not capable of giving informed consent to health care, I designate and appoint _______________________________________________________________________ (Name ) (Addrmporarily or permanently incapable of making health care decisions, and shall continue as long as the incapacity lasts or until I revoke it, whichever happens first. If my attending physician or his oective. This designation becomes effective when I cannot make health care decisions for myself as determined by my attending physician or designee, such as if I am unconscious, or if I am otherwise tefor me to the same extent that I could make such decisions for myself if I was capable of doing so, as recognized by RCW 11.94.010 and consistent with any existing valid Living Will or Health Care Dirhospital -2- Durable Power of Attorney for Health Care I intend to create a power of attorney (Health Care Agent) by appointing the person or persons designated herein to make health care decisions upon to act on your behalf should you be unable to do so. Each copy should state where the original is kept, and who else has copies. You should bring a copy with you each time you are admitted to a of safe keeping where they can be obtained in any emergency situation. Copies should be given to your close family members, physician(s), attorney, spiritual advisor, and any others who may be called such a physician, or someone employed by a health care facility in which you are a patient. -1- The original signed and witnessed copy should be kept by a designated person or in a designated placeDirective. Witnesses may not be: · · · Related to you by blood, marriage or adoption; Entitled to any portion of your estate or have any claim on it; or A physician attending you, a person employed by document if you choose. You must be 18 years of age or older to sign the Directive. The document must be signed by you in the presence of two witnesses. There are restrictions on who can witness the the same rights that you have to receive information about proposed health care, to review health care records, and to consent to the disclosure of healthcare records. You can limit that right in thisy express your desires to the Health Care Agent by including them in this document or my making them known in another manner. When acting under this document the Health Care Agent GENERALLY will have xercising his or her authority to make health care decisions for you, the Health Care Agent will have to act consistent with your express desires or, if they are unknown, in your best interest. You mawhich would actually speed up the natural process of dying. You may include specific limitations in this document on the authority of the Health Care Agent to make health care decision for you. When ere, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. A Health Care Agent will not be allowed to authorize "mercy killing," euthanasia or any procedure, the Health Care Agent to make health care decisions for you generally will include the authority to give informed consent, to refuse to give informed consent, or to withdraw informed consent to any caecisions for yourself. As long as you have the capacity to make informed health care decisions for yourself, you retain the right to make all medical and other health care decisions. The authority of ost health care decisions for you if you lose the capability to make informed health care decisions for yourself. This power is effective only when you lose the capacity to make informed health care d Health Care This is an important legal document. Before executing this document you should know these facts: This document gives the person you designate as your Health Care Agent the power to make mher party. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Notice To Person Executing the Washington State Durable Power Of Attorney Forore 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 whenever a document is negotiated with anotstitute for legal 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. BefWashington State Durable Power Of Attorney For Health Care This package contains a Durable Power Of Attorney For Health Care for the State of Washington. These forms are not intended and are not a sub Washington