Guide to Contents
INSTRUCTIONS ....................................................................... 14 pages
1. Effect of 07/01/07 Changes ................................................................................ 4
2. Definitions ............................................................................................................ 5
3. Certification of Declarant´s Condition ................................................................ 7
4. Use of Other Forms ............................................................................................. 8
5. How the New form differs from the former Living Will and Durable Power of
Attorney for Health Care forms ............................................................................... 8
6. The New Form Described ................................................................................... 9
7. Executing an Advance Directive for Health Care .............................................. 9
8. Health Care Agent ............................................................................................. 10
Restrictions
............................................................................................................ 10
Duty
........................................................................................................................ 10
Responsibilities
...................................................................................................... 10
Prohibited Activities
............................................................................................... 11
9. Refusal to Comply with Directive ..................................................................... 12
10. Revoking a Directive ........................................................................................ 13
11. Completed form ................................................................................................ 13
12. For Additional Information .............................................................................. 14
ADVANCE DIRECTIVE – FORM ............................................... 15 pages
Description of Four Parts ............................................................................... 1
Part One-Health Care Agent ............................................................... 3
ID of Agent ......................................................................................... 3
Back-up Agent(s) ............................................................................... 4
General Powers of Agent ................................................................... 5
Guidance for Agent ............................................................................ 6
Agent’s Powers after Declarant’s Death ........................................... 7
Part Two-Treatment Preferences ...................................................... 8
Conditions when Effective ................................................................. 9
Treatment Preferences ...................................................................... 9
Part Three – Guardianship ................................................................. 12
Part Four- Effectiveness/Signatures ................................................ 13