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BENEFICIARY SERVICES

215 West Loucks Street

Sheridan, Wyoming 82801-4226

Phone:    (307) 459-4653     Fax:    (413) 751-9511

Email:    info@beneficiaryservices.com  

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                                                    Instructions for

COMPLETING POWER OF ATTORNEY FOR HEALTH CARE

A health care agent is the person you appoint to make decisions about your medical care if you become unable to make these decisions yourself. Your agent can be a family member or a close friend whom you trust to make serious decisions. The person you name as your agent should clearly understand your wishes and be willing to accept the responsibility of making medical decisions for you. The person you appoint as your agent cannot be:

                                                    Unless:

the employee is related to you by blood, marriage, adoption or is your registered domestic partner;

                                                          or

the employee is your co-worker employed by the same health care institution, community care facility, or residential care facility for the elderly where you are a patient.

You can appoint a second and third person as your alternate agents. An alternate agent will step in if the person you name as agent is unable, unwilling or unavailable to act for you.

You can use the space provided to limit your agent’s authority.

Unless the form you sign limits the authority of your agent, your agent may make almost all health care decisions for you including:

a) consenting or refusing consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition;

b) selecting or discharging healthcare providers and institutions;

c) approving or disapproving diagnostic tests, surgical procedures, programs of medications and orders not to resuscitate; and

d) directing the provision, withholding and withdrawal of artificial nutrition and hydration and all other forms of health care.

Your agent is not authorized to consent to:

One of the strongest reasons for naming a health care agent is to have someone who can respond flexibly as your medical condition changes and can deal with situations that you did not foresee.

We urge you to talk with your health care agent about your future medical care and describe what you consider to be an acceptable "quality of life". If you want to record your wishes about specific treatments or conditions, you can use Part 2 of this document, Instructions for Health Care.

If you wish to cancel your Durable Power of Attorney for Health-Care Decisions you may do so by a signed writing or by personally notifying your supervising health care provider, of your intent to revoke.

Various statements about your agent’s authority. Cross out and initial any portion of these statements that do not reflect your wishes. Give your agent the authority to make anatomical gifts, authorize an autopsy, and direct the disposition of your remains after your death.

Cross out and initial any portion of these statements that do not reflect your wishes. nominates your agent or alternate agents to be your court appointed guardian should one become necessary. If this is not your intention, cross out and initial this section.

Yes. include instructions about certain care and treatment. If there are any specific instructions that you would like to include that are not already listed on the document you may list them. For example, you may want to include a sentence such as," I especially do not want cardiopulmonary resuscitation, a respirator or antibiotics." If you have appointed an agent, it is a good idea to write a statement such as, "Any questions about how to interpret or when to apply my Instructions for Health Care are to be decided by my agent."

You may cancel your Instructions for Health Care at any time and in any manner that communicates your intent to do so.

Your Advance Health Care Directive is an important legal document. Keep the original signed document in a secure but accessible place. Do not put the original document in a safe deposit box or any other security box that would keep others from having access to it.

Give photocopies of the signed original to your agent and alternate agent(s), doctor(s), family, close friends, clergy and anyone else who might become involved in your health care. If you enter a nursing home or hospital, have photocopies of your document placed in your medical records.

Be sure to talk to your agent and alternate agent(s), doctor(s), clergy, family and friends about your wishes concerning medical treatment. Discuss your wishes with them often, particularly if your medical condition changes.

If you want to make changes to your document after it has been signed and witnessed, you should complete a new document.

Remember, you can always revoke one or both sections of your Advance Health Care Directive.

Be aware that your document will not be effective in the event of a medical emergency. Ambulance personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are given a separate order that states otherwise. These orders, commonly called "non-hospital do-not-resuscitate orders," are designed for people whose poor health gives them little chance of benefiting from CPR.

These orders must be signed by your physician and instruct ambulance personnel not to attempt CPR if your heart or breathing should stop. Currently not all states have laws authorizing non-hospital do-not-resuscitate orders.