Minnesota Advance Health Care Directive Form 2

Clear Form
Minnesota
Health Care Directive
Purpose of
form
Part I.
Allows you to appoint another person (called an agent) to make
health care decisions if a doctor decides you are unable to do so.
Part II. Allows you to give written instructions about what you want.
Part III. Requires you and others to sign and date to make this legal.
My personal
information
My name: _______________________________________________
Address: ________________________________________________
_______________________________________________________
Home phone: (###) ______________________________________
Work phone: (###) ______________________________________
Date of birth: ___________________________________________
Social security #: _________________________________________
• I revoke all living wills, Durable Powers of Attorney for Health Care, or other written
advance health care directives I have signed in the past.
PART 1: Naming An Agent
Agent duties
My health care agent can:
• Make health care decisions for me if I am unable to make and
communicate decisions for myself.
• Make decisions based on any instructions in Part II of this document or
in other documents.
• Make decisions based on what he or she knows about my wishes.
• Act in my best interests if instructions are not available.
Agent roles
• When naming my health care agent, I must choose one of the
following. Initial the line in front of the statement you WANT.
______ I appoint one person to serve as my primary health care agent to
make decisions for me if I am unable to make or communicate
these decisions for myself. My primary agent may act alone. If
my primary agent is not able, willing, or available, each alternate
agent I name may act alone, in the order listed.
______ I appoint two or more persons to act together as my health care
agent. My primary agent and alternate agents must act together
and be in agreement when making decisions. If they are not all
readily available, or if they disagree, a majority of the agents who
are readily available may make decisions for me.
Act alone
Act together
Minnesota Health Care Directive / 1 of 4 pages
My primary
health care
agent
I appoint:
Agent’s name: ___________________________________________
Address: ________________________________________________
________________________________________________________
Home phone: (###) ____________________
Work phone: (###) ____________________
My first
alternate
health care
agent
Agent’s name: ___________________________________________
Address: ________________________________________________
________________________________________________________
Home phone: (###) ____________________
Work phone: (###) ____________________
My second
alternate
health care
agent
Agent’s name: ___________________________________________
Address: ________________________________________________
________________________________________________________
Home phone: (###) ____________________
Work phone: (###) ____________________
(If needed)
Reasons for
naming
health care
provider
I have named as my agent a health care provider, or employee of a
health care provider, who is currently or might be providing direct care
to me when decisions are needed. That person is not related to me by
blood, marriage, registered domestic partnership, or adoption. My
reasons for wanting to appoint that person as my agent are: ________
________________________________________________________
________________________________________________________
________________________________________________________
Powers of my
agent
If I am unable to decide or speak for myself, my agent has the power to:
• Consent to, refuse, or withdraw any health care, treatment, service, or
procedure
• Stop or not start health care which is keeping or might keep me alive
• Choose my health care providers
• Choose where I live when I need health care and what personal
security measures are needed to keep me safe.
• Obtain copies of my medical records and allow others to see them.
Minnesota Health Care Directive / 2 of 4 pages
Additional
powers of my
agent
If I WANT my agent to have any of the following powers, I must initial
the line in front of the statement.
I also authorize my agent to:
______ Make health care decisions for me even if I am able to decide or
speak for myself.
______ Carry out my wishes regarding a funeral, burial, or what will
happen to my body when I die.
______ Make decisions about mental health treatment including
electroconvulsive therapy and antipsychotic medication,
including neuroleptics.
______ In the event I am pregnant, determine whether to attempt to
continue my pregnancy to delivery based upon my agent’s
understanding of my values, preferences, or instructions.
______ Continue as my health care agent even if a dissolution,
annulment, or termination of our marriage or domestic
partnership is in process or has been completed.
Limiting the
powers of my
agent
I wish to limit the powers of my health care agent in the following
way(s): ________________________________________________
_______________________________________________________
PART II: Health Care Instructions
• I give the following instructions about my health care (my values and beliefs, what I
do and do not want, views about medical treatments or situations) ______________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
• I am attaching additional instructions concerning my health care values and
preferences. Initial one line: ______ Yes ______ No
• I authorize donation of organs, tissue, or other body parts after my death.
Initial one line: ______ Yes ______ No
Minnesota Health Care Directive / 3 of 4 pages
PART III: Making This Document Legal
My signature/
mark and
date
I agree with everything in this document and have made this document
willingly:
My signature: ____________________________________________
Date: __________________________________________________
(day / month / year)
Notary Public OR Witnesses
Notary Public
STATE OF MINNESOTA
NOTE: Must
not be named
as agent or
alternate
agent.
County of _______________________
This document was signed or acknowledged before me this _______
(day)
of _________________ , ______ by the above named principal.
(month)
(year)
_____________________________
Signature of Notary Public
Two
Witnesses
This document was signed or acknowledged in my presence. I am not
an agent or alternate agent in this document.
Witness Signature: ________________________________________
NOTE: Only
Address: ________________________________________________
one witness
can be a direct ________________________________________________________
Date: __________________________________________________
care provider
(month / day / year)
or employee
of a provider
on the day this Witness Signature: ________________________________________
Address: ________________________________________________
is signed.
________________________________________________________
Date: __________________________________________________
(month / day / year)
Minnesota Health Care Directive / 4 of 4 pages – Form current as of 2003