|I, ________________________, designate my partner, _________________________, to be my agent empowered with the following authority.|
1. VISITATION AUTHORITY: To give notice that, if I am admitted to a medical facility of any type, a nursing home, hospice, or similar health care, skilled nursing, or custodial facility, my agent, _____________________________, shall be designated as “family” as that term is defined by the Joint Commission on Accreditation of Healthcare Organizations. JCAHO defines “family” as “The person(s) who plays a significant role in the individual’s [patient’s] life. This may include a person(s) not legally related to the individual.” (Joint Commission Resources, JCR, 2001 Hospital Accreditation Standards, p. 322).
My agent shall have priority in being admitted to visit me in such facility. My partner, as my agent, is designated as the person to be consulted by medical or health care personnel concerning my care and treatment. This is in keeping with the Health Care Power of Attorney I executed. My agent shall also have the authority to determine who will be permitted to visit me while in the facility and during any recovery at home.
This authorization supersedes any preference given to parties related to me by blood or by law or other parties desiring to visit me. These instructions shall remain in full force and effect unless and until I freely give contrary written instructions to competent medical personnel on the premises involved. My subsequent disability or incapacity shall not affect these instructions.
2. RECEIPT OF PERSONAL PROPERTY: My agent shall also have the right to receive any and all items of personal property and effects that may be recovered from or about my person by any hospital, nursing home, other health care facility, police agency, or any other person or public/private entity at the time of my illness, disability, or death. This specifically includes cash or other liquid asset(s).
3. DISPOSITION OF REMAINS/AUTOPSY AUTHORIZATION/FUNERAL ARRANGEMENTS: My agent shall have the authority to authorize an autopsy if it is deemed necessary or is required by law. In matters concerning the disposition of my remains and funeral arrangements, I provide that my agent/partner, or any other person directed to dispose my remains, shall follow my instructions for any funeral services. Any limitations on this authority are specified in this document.
My agent is to direct the disposition of my remains by the following method:
burial ______ cremation ______ . The specific instructions are found in ______________________________________________________________________________________________ .
In this regard, my agent has the authority to make all decisions necessary for my obituary notice, funeral, any mortician’s role therein, burial services, interment or cremation of my body, including, but not limited to the selection of a casket or urn, selection, care and tending of a grave site, and selection of a gravestone including the inscription thereon.
4. SPECIFIC INSTRUCTIONS CONCERNING MY AGENT’S AUTHORITY OR LIMITATIONS THEREON: My agent shall have access to all medical records and information pertaining to me and concerning treatments, procedures, treatment plans, etc. This includes the right to disclose this information to other people. I explicitly authorize any medical or health care provider to release information requested by my agent to him/her and consider my agent an authorized person to receive such information under the Health Information Portability and Accessibility Act (HIPAA).
My agent has the authority to admit or discharge me from any hospital, nursing home, residential care, assisted living or similar facility, or service entity. My agent also has the authority to hire and fire medical, social service, and other support personnel. My agent is primarily responsible for my medical and health care.
State of _____________
County of ___________
Before me, a Notary Public in and for said County and State, personally appeared the above named, ___________________________, who acknowledged that he/she did sign the foregoing two-page instrument, and that the same is his/her free act and deed.
In Testimony Whereof, I have hereunto set my hand and official seal at __________, __________________, this _______ day of _________, 20___.