Free Health Care Directive

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Health Care Directive

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Your Information

Who is this Health Care Directive being created for?
e.g. Alex Garcia Smith

e.g. 101 Oak Street

e.g. Richmond






Frequently Asked Questions
Who can create a Health Care Directive?Anyone over the age of majority in your state with a sound mind can create a Health Care Directive. Having a sound mind generally means being mentally competent and capable of understanding the terms, implications and consequences of the contract.Will my information be kept private?Yes. LawDepot® is committed to protecting your privacy and ensuring that your visit to our website is completely secure. For more information, see our Privacy Policy.


Your Health Care Directive

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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:

Name: _______________________
Address: _______________________, _______________________, 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.

The remainder of this document will be available when you have purchased a license.


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