APPOINTMENT OF HEALTH CARE REPRESENTATIVE

I, [principal_name], residing at [principal_address], being of sound mind, hereby appoint [agent_name], residing at [agent_address] (Phone: [agent_phone], Email: None), as my primary Health Care Agent to make all medical decisions on my behalf if I am unable to make them myself.

ALTERNATE AGENT: If my primary agent is unable, unwilling, or ineligible to serve, I appoint [alternate_agent_name], residing at [alternate_agent_address] (Phone: [alternate_agent_phone]), as my alternate Health Care Agent.

EFFECTIVE TRIGGER & AGENT AUTHORITY

EFFECTIVE TRIGGER & AUTHORITY: This directive shall become effective only if my attending physician determines that I lack the capacity to make or communicate my own healthcare choices. My agent shall have full authority to request, receive, review, and consent to or refuse any medical treatment, surgical procedures, diagnostic tests, or medication, and to inspect my medical records in compliance with HIPAA regulations.

LIFE-SUSTAINING TREATMENT CHOICES

LIFE-SUSTAINING TREATMENT: My agent shall have full and absolute authority to make all decisions regarding life support, artificial nutrition, and hydration, consistent with what they believe are my values and best interests.

EXECUTION OF AGENT DESIGNATION

IN WITNESS WHEREOF, I have executed this directive on this ___ day of ________, 20__.

WITNESS ATTESTATION

WITNESS STATEMENT: We declare that the Principal signed this directive in our presence and that the Principal appeared to be of sound mind and free of duress. We certify that we are not the designated healthcare agent, healthcare providers, or employees of the healthcare facility treating the Principal.

NOTARY ACKNOWLEDGMENT

NOTARY ACKNOWLEDGMENT: STATE OF RHODE ISLAND, COUNTY OF ____________________. Subscribed, sworn to, and acknowledged before me by the Principal on this ___ day of ________, 20__.