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APPOINTMENT OF HEALTH CARE AGENT

I, _________________________, of ____________________________, ______________________________, Virginia, being of sound mind, voluntarily create this Appointment of Health Care Agent.

PRIOR DESIGNATIONS
I revoke any prior Appointment of Health Care Agent.

APPOINTMENT OF HEALTH CARE AGENT
In the event that I have been determined to be incapable of providing informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my agent for health care decisions:

_______________________
_______________________
_______________________, Virginia, __________
Telephone: ______________________________
Relationship: _______________________

AGENT'S AUTHORITY
My agent is authorized to act for me in all matters relating to my health care. My agent's powers include, but are not limited to:

  • Full power to consent, refuse consent, or withdraw consent to all medical, surgical, hospital and related health care treatments and procedures on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my agent by me;
  • Full power to make decisions on whether to provide, withhold, or withdraw artificial nutrition and hydration on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my agent by me;
  • Full power to review and receive any information regarding my physical or mental health, including medical and hospital records, in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), and the American Recovery and Reinvestment Act of 2009 ("ARRA");
  • Full power to sign any releases in order to obtain this information;
  • Full power to sign any documents required to request, withdraw, or refuse treatment or to be released or transferred to another medical facility.

My agent does not have authority to act for me for any other purpose unrelated to my health care. All of my agent's actions under this power during any period when I am unable to make or communicate health care decisions have the same effect on my heirs, devisees and personal representatives as if I were competent and acting for myself.

WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE
The designation of my health care agent will become effective on my inability to make or communicate health care decisions as determined by my attending physician and will remain in effect until my death, or until I regain competence and revoke it.

AGENT'S OBLIGATIONS
My agent will make health care decisions for me in accordance with this document, and in accordance with any instructions I give in a Living Will, Health Care Directive or other such document (either included in this document or as a separate document), and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent will make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent will consider my personal values to the extent known to my agent.

EFFECT OF COPY
A copy of this Appointment of Health Care Agent has the same effect as the original.

SEVERABILITY
If any part or parts of this Appointment of Health Care Agent is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of such part or parts shall not in any way affect the remaining parts, and this document shall be construed as though the invalid or illegal part or parts had never been included herein. But if the intent of this Appointment of Health Care Agent would be defeated by such construction, then it shall not be so construed.

SIGNATURE
This Appointment of Health Care Agent is made after careful reflection, while I am of sound mind. I am fully informed as to all contents of this document and understand the full import of this grant of powers to my agent. I fully understand that by signing this document, I will permit my agent to make health care decisions for me. I understand that my signature on this document gives my agent authority to provide, withhold, or withdraw consent to health care treatments or procedures on my behalf; to apply for public benefits to defray the cost of my health care; and to authorize my admission to or transfer from a health care facility. I further affirm that I am not signing this document as a condition of treatment or admission to a health care facility.

   

Signature:

_________________________

Name:

_________________________

Date:

____________________

Place:

____________________, Virginia


STATEMENT OF WITNESSES

I, the undersigned witness, declare that _________________________, the person who signed this document, is personally known to me and appears to be of sound mind and acting of her own free will and under no duress. She signed (or asked another to sign for her) this document in my presence. I further declare that I am at least 18 years of age, I am not entitled to any portion of _________________________'s estate, not financially responsible for _________________________'s health care, not named as _________________________'s health care Agent in this document, and that I am not married to _________________________ and not related to _________________________ by blood or adoption.


First witness

____________________________
(signature of witness)

____________________________
(print name)

_________________________________
(address)

________________________________
(city) (state)

___________________________
(date)


Second witness

____________________________
(signature of witness)

____________________________
(print name)

_________________________________
(address)

________________________________
(city) (state)

___________________________
(date)



RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________


ADVANCE MEDICAL DIRECTIVE

If I, _________________________, become incapacitated and am unable to direct my health care providers as to my own health care, I direct that this statement be read as a true reflection of my health care wishes.

DEFINITIONS
For the purposes of this document, the following definitions apply:

  1. "Artificially administered food and water" (or artificial nutrition and hydration) means the provision of nutrients or fluids by a tube inserted in vein, under the skin in the subcutaneous tissues, or in the stomach (gastrointestinal tract).
  2. "Attending physician" means the physician licensed by the state board of medicine, selected by or assigned to the patient, and who has primary responsibility for the treatment and care of the patient.
  3. "Comfort care" means treatment, including prescription medication, provided to the patient for the sole purpose of alleviating pain. Artificially administered food and water is not included.
  4. "Health care provider" or "provider" means any person licensed, certified, or otherwise authorized by law to administer health care in the ordinary course of business or practice of a profession.
  5. "Irreversible (Permanent) Coma" means a profound state of unconsciousness caused by disease, injury, poison, or other means and for which it has been determined that there exists no reasonable expectation of regaining consciousness.
  6. "Life-prolonging procedure" (or "life-sustaining procedure") means any medical procedure, treatment, or intervention which sustains, restores, or supplants a spontaneous vital function. In this document the term does not include sustenance and hydration administration, or the provision of medication or the performance of medical procedure, when such medication or procedure is deemed necessary to provide comfort care or to alleviate pain.
  7. "Persistent vegetative state" means a permanent and irreversible condition in which there is:
          a. The absence of voluntary action or cognitive behavior of any kind.
          b. An inability to communicate or interact purposefully with the environment.
  8. "Terminal condition" means a condition caused by injury, disease, or illness from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death.

MEDICAL DIRECTIONS AND END-OF-LIFE DECISIONS
I direct that my health care providers and others involved in my care, provide, withhold, or withdraw treatment in accordance with my directions below:

  1. If I have an incurable and irreversible (terminal) condition that will result in my death within a relatively short time, I direct that:
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.
  2. If I am diagnosed as being in an irreversible coma and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.
  3. If I am diagnosed as being in a persistent vegetative state and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that:
    • I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards.
    • I be artificially administered food and water, even if that has the effect of prolonging my life.
    • I be provided comfort care, and relief from pain, including any pain reduction medication, even if doing so would prolong my life.

PREGNANCY
Notwithstanding my other directions, if I am known to be pregnant, I do not want life-sustaining treatment, artificially provided nourishment or fluids and comfort care treatment, to be withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with their continued application.


ADDITIONAL INSTRUCTIONS
 I have no additional instructions. I understand that I may change the above-listed directives at any time by revoking this declaration and writing a new one.

EFFECT OF COPY
A copy of this Advance Medical Directive has the same effect as the original.

SEVERABILITY
If any part or parts of this Advance Medical Directive is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of such part or parts shall not in any way affect the remaining parts, and this document shall be construed as though the invalid or illegal part or parts had never been included herein. But if the intent of this Advance Medical Directive would be defeated by such construction, then it shall not be so construed.

SIGNATURE
This document is made upon careful reflection. Options that I have considered and rejected are not printed above. I confirm that the health care directions contained herein were made after careful consideration and in full awareness of other options that may have been available to me. I declare that I am an adult in the Commonwealth of Virginia, that I understand the full import of this declaration, and that I am emotionally and mentally competent to give these directions.

Signed at ____________________, in the Commonwealth of Virginia, this ________ day of ________________, ________.

Signature:

_________________________

Name:

_________________________

Address:

____________________________

 

______________________________, Virginia


STATEMENT OF WITNESSES

  1. I declare under penalty of perjury under the laws of the Commonwealth of Virginia that:
  2. The individual who signed or acknowledged this Advance Medical Directive, _________________________, is personally known to me, or her identity was proven to me by convincing evidence;
  3. _________________________ appeared to be eighteen (18) years of age or older, or of the legal age in this state to create this type of document;
  4. I am of at least eighteen (18) years of age and _________________________ signed or acknowledged this Advance Medical Directive in my presence;
  5. _________________________ appears to be of sound mind and under no duress, fraud, or undue influence;
  6. I am not a person appointed as _________________________'s health care agent;
  7. I am not _________________________'s health care provider, an employee of _________________________'s health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly; and
  8. I am not related to _________________________ by blood or marriage and I would not be entitled to any portion of _________________________'s estate on her death.

First witness

____________________________
(signature of witness)

_______________________
(print name)

____________________________
(address)

____________________________
(city) (state)

______________
(date)

Second witness

____________________________
(signature of witness)

_______________________
(print name)

____________________________
(address)

____________________________
(city) (state)

______________
(date)


RECORD OF COPIES

Record of people and institutions to whom I have given a signed copy of this document:

1. ____________________________________  Date: ____________________
2. ____________________________________  Date: ____________________
3. ____________________________________  Date: ____________________
4. ____________________________________  Date: ____________________
5. ____________________________________  Date: ____________________

Question Help
Health Care Directive Document Preview
Document PreviewAbout this Document

Last Updated October 6, 2023

What is a Living Will?

A Living Will is a document in which you can specify the medical treatments you wish to receive if you become incapacitated and can’t communicate.

As such, this document helps health care workers understand when to proceed with certain treatments when you’re:

  • In a coma
  • Terminally ill or injured
  • In the late stages of dementia
  • Near the end of life

The terms of your directive are binding once you sign the document. 

Is a Living Will the same as a Health Care Directive?

Generally, a Living Will and a Health Care Directive both dictate your health care preferences in the event of a medical emergency or incapacitation.

Some states use the terms Living Will and Health Care Directive interchangeably, while others use one term but not the other. The requirements for each document also vary by jurisdiction. LawDepot’s Living Will template will automatically customize your document to suit the laws in your selected location.

This document is sometimes called a Living Will because it only applies while you’re still alive. People also use the term Health Care Directive because it dictates which medical treatments and decisions you consent to. Other common names for this document include:

  • Advance Directive
  • Advance Medical Directive
  • Advance Decision Form
  • Personal Directive

In addition to your directives, LawDepot’s Living Will template allows you to grant decision-making powers to another person with a Medical Power of Attorney. 

What is a Medical Power of Attorney?

A Medical Power of Attorney is a document that appoints someone to make medical decisions on your behalf. This person becomes known as your health care agent or proxy.

If you’re incapacitated, your health care agent generally has the authority to:

  • Consent or refuse consent to treatments (per your Living Will)
  • Receive/review your medical and hospital records
  • Sign any medical releases or health care documents

A Medical Power of Attorney is also known as a Durable Power of Attorney for Health Care. For decision-making powers over legal, financial, and other personal areas of your life, use a Power of Attorney.

Who makes decisions if there’s no Medical Power of Attorney?

Typically, laws about family, health, and safety in your jurisdiction dictate who makes health care decisions for you if you’re unable to. In some states, surrogate consent laws create a hierarchy of people (e.g., family and friends) who should be able to convey your wishes accurately.

For example, in Arizona, the first five people health care workers defer to are:

  1. Any court-appointed guardian for making health care decisions
  2. Your health care agent
  3. Your spouse
  4. Your adult child
  5. Your domestic partner (if unmarried)

Notably, your spouse and family do not automatically have this authority if you’ve designated someone else as your health care agent. In this case, health care workers will defer to this person first and foremost.

Also, family members cannot override the directives you outlined in your Living Will. Nor can they override the decisions of your health care agent—who’s legally obligated to execute your Living Will. 

Why should I create a Living Will?

Creating a Living Will gives you control when you can’t speak for yourself and saves your family from making tough choices on your behalf.

Plus, when implementing a Medical Power of Attorney, you can discuss your wishes with someone you trust before you’re incapacitated. This way, you can trust they’ll make decisions in your best interest.

Imagine your family being asked to make medical decisions on your behalf. Would they struggle to agree on the best course of action? Who might argue or anguish over making “the right choice”? Avoid this situation by writing your health care wishes down in advance.

How to write a Living Will

Use LawDepot’s printable PDF template to customize a directive that suits your needs and preferences, while also complying with the laws of your state.

Specify your desired level of care if in a terminal condition, permanent coma, or vegetative state.

Terminally ill or injured means you have an incurable condition that limits your life expectancy. A permanent coma or vegetative state is when there’s a reasonable degree of certainty that you cannot think, feel, knowingly move, or be aware of living. Often, there’s little hope for improvement.

In these cases, consider if you wish to receive:

  • Life Support: life-sustaining procedures that restore function to an organ through medical intervention, such as CPR, defibrillators, assisted breathing, or dialysis.
  • Tube feeding: continuous life support that artificially administers food and water.
  • Comfort care: treatments that manage symptoms, pain relief, and quality of life.

2. Provide personal details

Include your full name and address.

If you can become pregnant, consider whether you want to suspend your Health Care Directive if there’s a chance your fetus can survive.

3. If desired, appoint a health care agent

LawDepot’s Living Will template allows you to include a Medical Power of Attorney. With this form, you can appoint a representative and an alternate to act if your first choice is unavailable. If doing so, include their:

  • Full name
  • Address
  • Phone number
  • Relationship to you

4. Add any special instructions, if applicable

Consider any unique circumstances or preferences you may want to include. For example, if your religious beliefs prohibit certain health care treatments.

Remember that you cannot include any instructions unrelated to health care planning.

5. Sign the document

Depending on your state’s law, you’ll need to sign your Living Will in front of at least two witnesses, a notary public, or both. LawDepot’s Living Will template will also include a Statement of Witnesses if your state requires it. In this statement, your witnesses swear they meet the legal requirements to witness and sign the document.

Also, it’s best practice to keep a record of any copies you make. For instance, you, your health care agent (if applicable), and your family doctor should each keep a copy. It’s helpful to keep a record of who owns a copy so that you know who to contact whenever you update your health care preferences.

Do I need to notarize a Living Will?

Even if your state doesn't require it, you may wish to notarize your document to help ensure its validity.

A notary public:

  • Verifies the identity of the signing parties
  • Ensures the parties understand the agreement
  • Puts their official stamp or seal on the document

How do I make changes to my Living Will?

You can make changes to your Living Will by:

  • Creating a new Living Will
  • Giving the new document and its copies to the appropriate people
  • Destroying any outdated versions

It's also important to let everyone in your family know where you keep your Living Will, so they can easily find it when needed.

What’s the difference between a Last Will and a Living Will?

Unlike a Living Will, a Last Will and Testament comes into effect when you die. Rather than dictate your choices for health care, a Last Will indicates how you’d like to divide your assets.

Still, both of these documents are powerful tools for managing your life and estate.

Related documents

  • Power of Attorney: grant someone authority to act on your behalf regarding your finances, family, or property
  • Last Will and Testament: dictate your legacy and how you’d like your estate divided upon your death
  • Child Medical Consent: give a temporary guardian the authority to make medical decisions on behalf of your child
  • Medical Records Release: request that your medical records be released to you or a third party
  • End-of-Life Plan: outline your wishes for memorial services and what to do with your remains

Related articles

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Your use of this site is subject to our Terms of Use, Disclaimer, Privacy Policy and Editorial Policy. LawDepot® is not a law firm and cannot provide legal advice. We provide information and software and you are responsible for appropriately using this material. ©2002-2023 LawDepot® (Sequiter Inc.). All Rights Reserved.

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©2002-2023 LawDepot® (Sequiter Inc.). All Rights Reserved. LawDepot® is not a law firm and cannot provide legal advice.

Use of this site is subject to our Terms of Use and Editorial Policy.

©2002-2023 LawDepot® (Sequiter Inc.). All Rights Reserved. LawDepot® is not a law firm and cannot provide legal advice.

Use of this site is subject to our Terms of Use and Editorial Policy.

Your use of this site is subject to our Terms of Use, Disclaimer, Privacy Policy and Editorial Policy. LawDepot® is not a law firm and cannot provide legal advice.
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