make your free idaho medical power of attorney

durable power of attorney for health care

. designation of health care agent. i, , of , , do hereby designate and appoint:

(none of the following may be designated as your agent: (1) your treating health care provider, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility, or (4) a nonrelative employee of an operator of a community care facility.)

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,

. 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.

. authority of agent. subject to any limitations in this document, i 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 the authority under this durable power of attorney for health care, my agent shall act consistently 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. my agent's authority is subject to the special provisions and limitations stated in my living will. if my desires regarding a particular health care decision are not known to my agent, then my agent shall make the decision for me based upon what my agent believes to be in my best interests.

. inspection and disclosure of information relating to my physical or mental health. subject to any limitations in this document, my agent has the power and authority to:

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. consent to the disclosure of this information to others.

. signing documents, waivers, and releases. where necessary to implement the heath care decisions that my agent is authorized by this document to make, my health care agent has the power and authority to execute on my behalf any of the following:

a. documents to authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care or assisted living or similar facility or service;

b. documents titled or purporting to be "consent to permit treatment" or "refusal to permit treatment"; or

c. any necessary waiver or release from liability required by a hospital or physician.

. anatomical gifts. i to make anatomical gifts of part or all of my body for medical purposes, to the extent permitted by law.

. prior designations revoked. i revoke any prior durable power of attorney for health care.

. general provisions.

1. hold harmless. all persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.

2. severability. if any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.

3. statement of intentions. it is my intent that this document be legally binding and effective. if the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which i am unable to make such decisions.

date and signature of principal

(you must date and sign this document)

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.

i sign my name to this document on the _____ day of ____________________, _____, at _________________________, idaho.

statement of witnesses

(it is recommended that this document be signed by two qualified witnesses who are present when you sign or acknowledge your signature. if you have attached any additional pages to this form, you must date and sign each of the additional pages at the same time you date and sign this document.)

(none of the following may be used as a witness: (1) a person you designate as your agent or alternate agent, (2) a health care provider, (3) an employee of a health care provider, (4) the operator of a community care facility, (5) an employee of an operator of a community care facility. at least one of the witnesses may make the additional declaration set out following the place where the witnesses sign.)

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 , that signed or acknowledged this document in my presence, that 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.

date: _________________________

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 by blood, marriage, or adoption, and, to the best of my knowledge, i am not entitled to any part of the estate of upon the death of under a will now existing or by operation of law.

signature: ________________________________________

signature: ________________________________________