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Idaho Advance Health Directive
Idaho Advance Health Directive
Idaho Advance Health Directive
Idaho Advance Health Directive
Idaho Advance Health Directive
Idaho Advance Health Directive
Idaho Advance Health Directive
Idaho Advance Health Directive
Idaho Advance Health Directive
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Idaho Advance Health Directive

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  • 1. INSTRUCTIONS ———— PRINT YOUR NAME AND ADDRESS PRINT THE NAME, ADDRESS AND HOME AND WORK TELEPHONE NUMBERS OF YOUR AGENT © 2004 LAST ACTS PARTNERSHIP, INC. IDAHO DURABLE POWER OF ATTORNEY FOR HEALTH CARE ————————————— 1. Designation of Health Care Agent. I, _____________________________________________________________________, (name) ____________________________________________________________, do hereby (address) designate and appoint _________________________________________________ (name of agent) _______________________________________________________________________ (address) _______________________________________________________________________ (work telephone number) (home telephone number) as my attorney in fact (agent) to make health care decisions for me as authorized in this document. For the purposes of this document, “health care decision” means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual’s physical condition. 2. Creation of Durable Power of Attorney for Health Care. By this document I intend to create a durable power of attorney for health care. This power of attorney shall not be affected by my subsequent incapacity. 3. General Statement of Authority Granted. Subject to any limitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures, including such desires set forth in a living will or similar document executed by me, if any. (If you want to limit the authority of your agent to make health care decisions for you, you can state the limitations in paragraph 4 [“Statement of Desires, Special Provisions, and Limitations”] below. You can indicate your desires by including a statement of your desires in the same paragraph.)
  • 2. ADD PERSONAL INSTRUCTIONS (IF ANY) © 2004 LAST ACTS PARTNERSHIP, INC. 4. Statement of Desires, Special Provisions, and Limitations. (If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit in any other way the authority given your agent by this document, you should state the limits in the space below. If you do not state any limits, your agent will have broad powers to make health care decisions for you, except to the extent that there are limits provided by law.) In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated in a living will or similar document executed by me, if any. Additional statement of desires, special provisions, and limitations: (You may attach additional pages if you need more space to complete your statement. If you attach additional pages, you must date and sign each of the additional pages at the same time you date and sign this document.) 5. Inspection and Disclosure of Information Relating to my Physical or Mental Health. A. General Grant of Power and Authority Subject to any limitations in this document, my agent has the power and authority to do all of the following: (a) Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records. (b) Execute on my behalf any releases or other documents that may be required in order to obtain this information. (c) Consent to the disclosure of this information. (d) Consent to the donation of any of my organs for medical purposes. (If you want to limit the authority of your agent to receive and disclose information relating to your health, you must state the limitations in paragraph 4 [“Statement of Desires, Special Provisions, and Limitations”] above.) IDAHO DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 2 OF 6
  • 3. ALTERNATE AGENTS ——— © 2004 LAST ACTS PARTNERSHIP, INC. IDAHO DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 3 OF 6 B. HIPAA Release Authority. My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose, and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present, or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. 6. Signing Documents, Waivers, and Releases. Where necessary to implement the health care decisions that my agent is authorized by this document to make, my agent has the power and authority to execute on my behalf all of the following: (a) Documents titled or purporting to be a “Refusal to Permit Treatment” and “Leaving Hospital Against Medical Advice.” (b) Any necessary waiver or release from liability required by a hospital or physician. 7. Designation of Alternate Agents. If the person designated as my agent in paragraph 1 is not available or becomes ineligible to act as my agent to make a health care decision for me or loses the mental capacity to make health care decisions for me, or if I revoke that person’s appointment or authority to act as my agent to make health care decisions for me, then I designate and appoint the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below:
  • 4. PRINT THE NAMES, ADDRESSES AND TELEPHONE NUMBERS OF YOUR ALTERNATE AGENTS SIGN AND DATE YOUR DOCUMENT © 2004 LAST ACTS PARTNERSHIP, INC. A. First Alternate Agent ________________________________________________ (name of first alternate agent) _______________________________________________________________________ (address) _______________________________________________________________________ (home telephone number) (work telephone number) B. Second Alternate Agent _____________________________________________ (name of second alternate agent) _______________________________________________________________________ (address) _______________________________________________________________________ (home telephone number) (work telephone number) 8. Prior Designations Revoked. I revoke any prior durable power of attorney for health care. 9. Date and Signature of Principal. (You must date and sign this power of attorney.) I sign my name to this Statutory Form Durable Power of Attorney for Health Care on __________________ at ____________________________, _________________. (date) (city) (state) _______________________________________________________________________ (you sign here) 10. Notary. IDAHO DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 4 OF 6
  • 5. WITNESSING PROCEDURE ———— A NOTARY PUBLIC MUST COMPLETE THIS SECTION OR TWO WITNESSES MUST SIGN AND DATE YOUR DOCUMENT AND PRINT THEIR NAMES AND ADDRESSES WITNESS #1 © 2004 LAST ACTS PARTNERSHIP, INC. IDAHO DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 5 OF 6 State of Idaho County of _________________________ ss. On this _____________ day of _____________________ 20 _______, before me personally appeared ___________________________________________________ (full name of signer of instrument) to me known (or proved to me on basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed it. I declare under penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. _________________________________________ (signature of notary) OR 11. Statement of Witnesses. I declare under penalty of perjury under the laws of Idaho that the person who signed or acknowledged this document is personally known to me (or proved to me on the basis of convincing evidence) to be the principal, that the principal signed or acknowledged this durable power of attorney 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, and that I am not a health care provider, an employee of a health care provider, the operator of a community care facility, nor an employee of an operator of a community care facility. Signature: ____________________________________________________________ Print name: __________________________________________________________ Residence address: ___________________________________________________ Date: ________________________ Signature: ____________________________________________________________
  • 6. Print name: __________________________________________________________ Residence address: ___________________________________________________ Date: ________________________ (At least one of the above witnesses must also sign) I further declare under penalty of perjury under the laws of Idaho that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law. Signature: ____________________________________________________________ Signature: ____________________________________________________________ WITNESS #2 AT LEAST ONE OF YOUR WITNESSES MUST ALSO AGREE WITH THIS STATEMENT AND SIGN HERE © 2004 LAST ACTS PARTNERSHIP, INC. IDAHO DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 6 OF 6 Courtesy of Last Acts Partnership, Inc. 7/04 1620 Eye Street, NW Suite 200 Washington, DC 20006 800-989-9455
  • 7. IDAHO LIVING WILL A DIRECTIVE TO WITHHOLD OR TO PROVIDE TREATMENT ———————————— To my family, my relatives, my friends, my physicians, my employers, and all others whom it may concern: Directive made this ____________ day of ___________________ 20 _________. I, _____________________________________________________________________, (name) being of sound mind, willfully, and voluntarily make known my desire that my life shall not be prolonged artificially under the circumstances set forth below, do hereby declare: 1. If at any time I should have an incurable injury, disease, illness or condition certified to be terminal by two medical doctors who have examined me, and where the application of life-sustaining procedures of any kind would serve only to prolong artificially the moment of my death, and where a medical doctor determines that my death is imminent, whether or not life-sustaining procedures are utilized, or I have been diagnosed as being in a persistent vegetative state, I direct that the following marked expression of my intent be followed and that I be permitted to die naturally, and that I receive any medical treatment or care that may be required to keep me free of pain or distress. (continued on the next page) INSTRUCTIONS ———— PRINT THE DATE PRINT YOUR NAME © 2004 LAST ACTS PARTNERSHIP, INC.
  • 8. CHECK ONE PARAGRAPH: ____ If at any time I should become unable to communicate my instructions, then I direct that all medical treatment, care, and nutrition and hydration necessary to restore my health, sustain my life, and to abolish or alleviate pain or distress be provided to me. Nutrition and hydration shall not be withheld or withdrawn from me if I would die from malnutrition or dehydration rather than from my injury, disease, illness or condition. ____ If at any time I should become unable to communicate my instructions and where the application of artificial life-sustaining procedures shall serve only to prolong artificially the moment of my death, I direct such procedures be withheld or withdrawn except for the administration of nutrition and hydration as follows: (If you checked this paragraph, check one of the following sentences. If you checked this paragraph and none of the following sentences is checked, then both nutrition and hydration will be administered.) ____Only hydration shall be administered. ____Only nutrition shall be administered. ____Both nutrition and hydration shall be administered. ____ If at any time I should become unable to communicate my instructions and where the application of artificial life-sustaining procedures shall serve only to prolong artificially the moment of death, I direct such procedures be withheld or withdrawn including withdrawal of the administration of nutrition and hydration. Other directions: CHECK THE PARAGRAPH THAT REFLECTS YOUR WISHES IF YOU DO NOT WANT ARTIFICIAL NUTRITION AND HYDRATION, CHECK THIS PARAGRAPH ADD PERSONAL INSTRUCTIONS (IF ANY) © 2004 LAST ACTS PARTNERSHIP, INC. IDAHO LIVING WILL — PAGE 2 OF 3
  • 9. SIGN THE DOCUMENT AND PRINT YOUR CITY, COUNTY, AND STATE OF RESIDENCE WITNESSING PROCEDURE ———— YOUR WITNESSES MUST SIGN AND PRINT THEIR ADDRESSES © 2004 LAST ACTS PARTNERSHIP, INC. 2. In the absence of my ability to give further directions regarding my treatment, including life-sustaining procedures, it is my intention that this directive shall be honored by my family and physicians as the final expression of my legal right to refuse or accept medical and surgical treatment, and I accept the consequences of such refusal. 3. If I have been diagnosed as pregnant, this directive shall have no force during the course of my pregnancy. 4. I understand the full importance of this directive and am emotionally and mentally competent to make this directive. No participant in the making of this directive or in its being carried into effect, whether it be a medical doctor, my spouse, a relative, friend or any other person shall be held responsible in any way, legally, professionally or socially, for complying with my directions. _______________________________________________ (signature of principal) _______________________________________________ (city, county, and state of residence) The declarant has been known to me personally and I believe him/her to be of sound mind. Witness ______________________________________________________________ Address ______________________________________________________________ Witness ______________________________________________________________ Address ______________________________________________________________ IDAHO LIVING WILL — PAGE 3 OF 3 Courtesy of Last Acts Partnership, Inc. 7/04 1620 Eye Street, NW Suite 200 Washington, DC 20006 800-989-9455

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