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The following is the Washington State's Health Care Power of Attorney Form that your doctor and family will need to be able to follow your wishes should you be unable to speak for yourself. The Advanced Medical Directive should be attached to this form in order to clarify your wishes. Be sure to place all this information with the doctor, hospital, and/or family member, since at these times many people forget to locate important paperwork
 
 

Your First Name:		Middle and Last Name:
Street Address:		City, St,Zip
Home Phone:		Work Phone
Soc.Sec.#		Birthplace:
Date of Birth		Maiden/Other Names

1. I, (your name)_________________________________, hereby appoint:

Name:	Relationship:
Street:	City, St.Zip:
Home Phone:	Work Phone:

as my attorney-in-fact to make health-care decisions for me if I become unable to make my own health-care decisions. This gives my attorney-in-fact the power to grant, refuse, or withdraw consent on my behalf for any health-care service, treatment or procedure, even though my death may ensue. My attorney-in-fact has the authority to talk to health-care personnel, get information, have assess to my medical records and sign forms necessary to carry out these decisions. My attorney-in-fact also has authority to authorize my admission to or discharge from any hospital, nursing home, residential care, assisted living or similar facility or service, and to contact on my behalf for any health care related service or facility (without my attorney-in-fact incurring personal financial liability for such contracts).
 

2. If the person named as my attorney-in-fact is not available or is unable to act as my attorney-in-fact, I appoint the following person(s) to serve in the order listed below:
A.

Name:	Relationship:
Street:	City, St.Zip:
Home Phone:	Work Phone:

B.

Name:	Relationship:
Street:	City, St.Zip:
Home Phone:	Work Phone:

3. With this document, I intend to create a power of attorney for health-care, which shall take effect upon and only during any period in which, in the opinion of my attending physician and one other physician, I am unable to make or communicate a choice regarding a particular health-care decision. My attorney-in-fact shall make health-care decisions as I direct below or as I make known to my attorney-in-fact in some other way. If my attorney-in-fact is unable to determine the choice I would want made, then my attorney-in-fact shall make a choice for me based upon what my attorney-in-fact believes to be in my best interest.

(A) STATEMENT OF DIRECTIVES CONCERNING LIFE-SUSTAINING CARE, TREATMENT SERVICES, AND PROCEDURES (the directions herein apply to all forms of life-sustaining treatments which include but are not limited to mechanical ventilation, cardiopulmonary resuscitation, kidney dialysis, antibiotic therapy, and artificial nutrition and hydration, unless otherwise limited in these directions).

See Advance Medical Directive Dated: ___________________

Other comments:  _______________________________________________________

____________________________________________________________________

(B) SPECIAL PROVISIONS AND LIMITATIONS (These limitations and/or instructions apply to specific types of treatment that are inconsistent with my religious beliefs or unacceptable to me for any other reason, such as blood transfusions, convulsive therapy, amputation, psycho surgery, voluntary admission to a mental institution, etc. And include treatments that I have discussed with my attorney-in-fact).

See Advance Medical Directive Dated:      ___________________

Other comments:    _________________________________________________

______________________________________________________________________

4. To the extent that I am permitted by law to do so, I herewith nominate my attorney-in-fact to serve as my guardian, conservator and/or in any similar representative capacity. If I am not permitted by law to make a nomination, then I request in the strongest possible terms that any court consider this nomination.