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Wyoming ate) Advance Health Care Directive __________________ _____________________________________________________________ Advance Health Care Directive (Signature of notary public in lieu of witnesses) ___________________________________ (d___ Date: _______________ Print Name: ___________________________________________________ Telephone Number: _____________________________________________ Residence Address: ___________________________n operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility. Witness #2: Signature: ____________________________ted as attorney-in-fact by this document, and that I am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of al, that the principal signed or acknowledged this document in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appoin_____________________________________ I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the principa______________________________________________ Telephone Number: _____________________________________________ Residence Address: _____________________________________________ ________________________e operator of a residential care facility, nor an employee of an operator of a residential care facility. Witness #1: Signature: _______________________________ Date: _______________ Print Name: _____nd that I am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of an operator of a community care facility, thd this document in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as attorney-in-fact by this document, alare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the principal, that the principal signed or acknowledge______________________________ Residence Address: _____________________________________________ _____________________________________________________________ (Optional) SIGNATURES OF WITNESSES: I decNATURES: Sign and date the form here: Signature: _______________________________ Date: _______________ Print Name: ___________________________________________________ Telephone Number: _______________ code) _____________________________________________ (phone) Advance Health Care Directive ******************** (12) EFFECT OF COPY: A copy of this form has the same effect as the original. (13) SIGy physician: _____________________________________________ (name of physician) _____________________________________________ (address) _____________________________________________ (city) (state) (zip___________________________________ (phone) If the physician I have designated above is not willing, able or reasonably available to act as my primary physician, I designate the following as my primar_________________________________________ (name of physician) _____________________________________________ (address) _____________________________________________ (city) (state) (zip code) __________: (i) Any purpose authorized by law; (ii) Transplantation; (iii) Therapy; (iv) Research; (v) Medical education. PART 4 (OPTIONAL) (11) I designate the following physician as my primary physician: _____________________________________________ ______________________________________________________________________ (d) My gift is for the following purposes (strike any of the following you do not want)pon my death (initial applicable box): (a) I give my body, or (b) I give any needed organs, tissues or parts, or (c) I give the following organs, tissues or parts only: _________________________________ ______________________________________________________________________________ (Add additional sheets if needed.) Advance Health Care Directive PART 3 DONATION OF ORGANS AT DEATH (OPTIONAL) (10) U____________________________________________ ______________________________________________________________________________ ___________________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________uctions you have given above, you may do so here.) I direct that:_______________________________________________________________ _________________________________________________________________________________________________________________________________ (9) OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instr_____________________ ______________________________________________________________________________ ______________________________________________________________________________ ____________________F FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times: _________________________________________________________f the choice I have made in paragraph (6). If I initial this box , artificial hydration must be provided regardless of my condition and regardless of the choice I have made in paragraph (6). (8) RELIEin accordance with the choice I have made in paragraph (6) unless I initial the following box. If I initial this box , artificial nutrition must be provided regardless of my condition and regardless od as long as possible within the limits of generally accepted health care standards. (7) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and hydration must be provided, withheld or withdrawn medical certainty, I will not regain consciousness, or (iii) the likely risks and burdens of treatment would outweigh the expected benefits, OR (b) Choice To Prolong Life I want my life to be prolongeant my life to be prolonged if (i) I have an incurable and irreversible condition that will result in my death within a relatively short time, (ii) I become unconscious and, to a reasonable degree of ect that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with the choice I have initialed below: (a) Choice Not To Prolong Life I do not w__________ I do not nominate anyone to be guardian. Advance Health Care Directive PART 2 INSTRUCTIONS FOR HEALTH CARE Please strike any wording that you do not want. (6) END-OF-LIFE DECISIONS: I dirin the order designated: _____________________________________________________________ _____________________________________________________________ ___________________________________________________on needs to be appointed for me by a court, (please initial one): I nominate the agent(s) whom I named in this form in the order designated to act as guardian. I nominate the following to be guardian determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent. (5) NOMINATION OF GUARDIAN: If a guardian of my persgive in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent care decisions for me takes effect immediately. (4) AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I supervising health care provider determines that I lack the capacity to make my own health care decisions unless I initial the following box. If I initial this box my agent's authority to make health________________________________________________________________________ (Add additional sheets if needed.) (3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my___________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________________________ ______________________________________________________________________________ ___________________________________________ for me, including decisions to provide, withhold or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:_________________________ _(city) (state) (zip code) __________________ (home phone) __________________ (work phone) Advance Health Care Directive (2) AGENT'S AUTHORITY: My agent is authorized to make all health care decisionss my second alternate agent: _________________________________ (name of individual you choose as second alternate agent) _________________________________ (address) _________________________________ ____ (work phone) OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able or reasonably available to make a health care decision for me, I designate af individual you choose as first alternate agent) _________________________________ (address) _________________________________ (city) (state) (zip code) __________________ (home phone) ______________agent's authority or if my agent is not willing, able or reasonably available to make a health care decision for me, I designate as my first alternate agent: _________________________________ (name oagent) _________________________________ (address) _________________________________ (city) (state) (zip code) __________________ (home phone) __________________ (work phone) OPTIONAL: If I revoke my EY FOR HEALTH CARE (1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me: _________________________________ (name of individual you choose as be discussed with a tax professional. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at www.findlegalforms.com Advance Health Care Directive POWER OF ATTORNsure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should d/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 or signed without consulting an attorney first to make rranties 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 is willing to take the responsibility. You have the right to revoke this advance health care directive or replace this form at any time. These forms are provided "as is" and no implied or express wa institution at which you are receiving care, and to any health care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes anry public or, in the alternative, be witnessed by two (2) witnesses. Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health careate a supervising health care provider to have primary responsibility for your health care. After completing this form, sign and date the form at the end. This form must either be signed before a nota additional wishes. Advance Health Care Directive Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death. Part 4 of this form lets you design, including the provision of artificial nutrition and hydration, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out anyu give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive medication and orders not to resuscitate; and (d) Direct the provision, withholding or withdrawal of artificial nutrition and hydration and all other forms of health care. Part 2 of this form lets yoiagnose or otherwise affect a physical or mental condition; (b) Select or discharge health care providers and institutions; (c) Approve or disapprove diagnostic tests, surgical procedures, programs ofay have to be made. If you choose not to limit the authority of your agent, your agent will have the right to: (a) Consent or refuse consent to any care, treatment, service or procedure to maintain, dsions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that m operator or employee of a residential or community care facility at which you are receiving care. Unless the form you sign limits the authority of your agent, your agent may make all health care deci You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner,l as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable.se this form, you may complete or modify all or any part of it. You are free to use a different form. Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individua for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your supervising health care provider. If you uctive Instructions Wyoming Advance Health Care Directive You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisionsor health care. (e) An advance health care directive that conflicts with an earlier advance health care directive revokes the earlier directive to the extent of the conflict. Advance Health Care Dire(d) A decree of annulment, divorce, dissolution of marriage or legal separation revokes a previous designation of a spouse as agent unless otherwise specified in the decree or in a power of attorney fho is informed of a revocation shall promptly communicate the fact of the revocation to the supervising health care provider and to any health care institution at which the patient is receiving care. hall, as soon as possible after the revocation, be documented in a writing signed and dated by the individual or a witness to the revocation. (c) A health care provider, agent, guardian or surrogate wpacity may revoke all or part of an advance health care directive, other than the designation of an agent, at any time and in any manner that communicates an intention to revoke. Any oral revocation s Revocation of advance health care directive. (a) An individual with capacity may revoke the designation of an agent only by a signed writing. Advance Health Care Directive (b) An individual with caination of a guardian of the person. (j) An advance health care directive is valid for purposes of this act if it complied with the applicable law at the time of execution or communication. 35-22-404.ent known to the agent. (g) A health care decision made by an agent for a principal is effective without judicial approval. (h) A written advance health care directive may include the individual's nomecision in accordance with the agent's determination of the principal's best interest. In determining the principal's best interest, the agent shall consider the principal's personal values to the ext(f) An agent shall make a health care decision in accordance with the principal's advance health care directive and other wishes to the extent known to the agent. Otherwise, the agent shall make the dan individual instruction or the authority of an agent, shall be made by the primary physician, but the supervising health care provider may make the decision if the primary physician is unavailable. capacity. (e) Unless otherwise specified in a written advance health care directive, a determination that an individual lacks or has recovered capacity, or that another condition exists that affects r health care, the authority of an agent becomes effective only upon a determination that the principal lacks capacity, and ceases to be effective upon a determination that the principal has recoveredare facility or employee of the operator or facility; (iv) The operator of a residential care facility or employee of the operator or facility. (d) Unless otherwise specified in a power of attorney foitness for a power of attorney for health care: (i) A treating health care provider or employee of the provider; (ii) The attorney-in-fact nominated in the writing; (iii) The operator of a community c of an operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility. (c) None of the following shall be used as a wppointed as attorney-in-fact by this document, and that I am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employeed or acknowledged this document in my presence, that the principal appears to be of sound mind and under no duress, Advance Health Care Directive fraud or undue influence, that I am not the person asubstance: I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the principal, that the principal signeeach of whom witnessed either the signing of the instrument by the principal or the principal's acknowledgement of the signature or of the instrument, each witness making the following declaration in ity care facility at which the principal is receiving care. The durable power of attorney must either be sworn and acknowledged before a notary public or must be signed by at least two (2) witnesses, later incapacity and may include individual instructions. Unless related to the principal by blood, marriage or adoption, an agent may not be an owner, operator or employee of a residential or commun must be in writing and signed by the principal or by another person in the principal's presence and at the principal's expressed direction. The power remains in effect notwithstanding the principal'sdult or emancipated minor may execute a power of attorney for health care, which may authorize the agent to make any health care decision the principal could have made while having capacity. The power) An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises. (b) An ath this act as the person or persons who are to make those decisions in accordance with this act. (xxi) "This act" means W.S. 35-22-401 through 35-22-416. 35-22-403. Advance health care directives. (ae to initiate, continue or discontinue the use of a life sustaining procedure on behalf of a patient who lacks capacity; and (D) Are identified by the supervising health care provider in accordance wie; (xx) "Surrogate" means an adult individual or individuals who: (A) Have capacity; (B) Are reasonably available; (C) Are willing to make health care decisions, including decisions to initiate, refusbject to the jurisdiction of the United States; (xix) "Supervising health care provider" means the primary health care provider who has undertaken primary responsibility for an individual's health caric mental illness; Advance Health Care Directive (xviii) "State" means a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico or a territory or insular possession suient's health care needs; (xvii) "Residential care facility" means a public or private facility providing for the residential and health care needs of the elderly or persons with disabilities or chron to be contacted with a level of diligence appropriate to the seriousness and urgency of a patient's health care needs and willing and able to act in a timely manner considering the urgency of the patual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes the responsibility; (xvi) "Reasonably available" means ableanced practice registered nurse; (xv) "Primary physician" means a physician designated by an individual or the individual's agent, guardian or surrogate, to have primary responsibility for the individ "Primary health care provider" means any person licensed under the Wyoming statutes practicing within the scope of that license as a licensed physician, licensed physician's assistant or licensed advmedicine under the Wyoming Medical Practice Act; (xiii) "Power of attorney for health care" means the designation of an agent to make health care decisions for the individual granting the power; (xiv)ry course of business; (xi) "Individual instruction" means an individual's direction concerning a health care decision for the individual; (xii) "Physician" means an individual authorized to practice other forms of health care. (x) "Health care institution" means an institution, facility or agency licensed, certified or otherwise authorized or permitted by law to provide health care in the ordinasapproval of diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate; and (C) Directions to provide, withhold or withdraw artificial nutrition and hydration and alldividual or the individual's agent, guardian, or surrogate, regarding the individual's health care, including: (A) Selection and discharge of health care providers and institutions; (B) Approval or dicare" means any care, treatment, service or procedure to maintain, diagnose or otherwise affect an individual's physical or mental condition; (ix) "Health care decision" means a decision made by an inrough 14-1-206; (vii) "Guardian" means a judicially appointed guardian or conservator having authority to make a health care decision for an individual; Advance Health Care Directive (viii) "Health " means a public or private facility responsible for the day-to-day care of persons with disabilities; (vi) "Emancipated minor" means a minor who has become emancipated as provided in W.S. 14-1-201 thy" means an individual's ability to understand the significant benefits, risks and alternatives to proposed health care and to make and communicate a health care decision; (v) "Community care facilityited to, nasogastric tubes, gastrostomies, jejunostomies and intravenous infusions. Artificial nutrition and hydration does not include assisted feeding, such as spoon or bottle feeding; (iv) "Capacitrition and hydration" means supplying food and water through a conduit, such as a tube or an intravenous line where the recipient is not required to chew or swallow voluntarily, including, but not limfor health care, or both; (ii) "Agent" means an individual designated in a power of attorney for health care to make a health care decision for the individual granting the power; (iii) "Artificial nutyoming Statutes relating to Advance Health Care Directives. 35-22-402. Definitions. (a) As used in this act: (i) "Advance health care directive" means an individual instruction or a power of attorney ive. This Wyoming Advance Health Care Directive is based on Title 35 Chapter 22 Article 4 (35-22401) et. Seq. of the Wyoming Statutes. For your convenience, we have included useful excerpts from the Wrective; and 3) the Wyoming Advance Health Care Directive. This form includes a power of attorney for health care and instructions for health care, usually referred to as an advance health care directInformation Wyoming Advance Health Care Directive This packet includes: 1) Information regarding the Wyoming Advance Health Care Directive; 2) Instructions regarding the Wyoming Advance Health Care Di Wyoming