Living Will and Designation of Health Care Surrogate/Health Care Power of Attorney

A Living Will directs your physician as to whether or not to cease life-sustaining procedures which would serve only to prolong your death if you are terminally ill. It gives guidelines for your physician to follow, as well as clarifies your intent as to life-sustaining procedures.

A Health Care Surrogate or Health Care Power of Attorney designates a Health Care Representative if you are incapable of making health care decisions or providing informed consent for medical treatment. It must also account for HIPAA (Health Insurance Portability and Accountability Act) of 1996 to be effective. If your Health Care Surrogate or Health Care Power of Attorney was drafted prior to 2003, then it does not contain the HIPAA language and is likely not valid.

Contact Information: Please Provide your contact information:
Legal Names: List any prior legal names, nicknames, or maiden names:
Health Care Information:

Your Health Care Surrogate is the person you designate to make decisions on your behalf in the event you are unable.

Health Care Surrogate:
Alternate Health Care Information:

In the event your Health Care Surrogate is unable to or unwilling to make decisions on your behalf, who would you like to designate as your

Alternate Health Care Surrogate:
 

Please do not include any confidential or sensitive information in this form. This form sends information by non-encrypted e-mail which is not secure.

Submitting this form does not create an attorney-client relationship.


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