Tuesday, November 24, 2009

Example Health Care Proxy

(1) Health Care Agent
I, Robert Fielding, hereby appoint: Bob Oberg, of 1109 Mets Ct., Santee, Ca 90210, (619) 562-4002, as my “health care proxy,” to make any and all health care decisions for me, except to the extent that I state otherwise or that I specify in a Living Will document. This proxy shall take effect only when and if I become unable to make my own health care decisions and have no reasonable hope of recovery. The judgment of my inability to make health care decisions is as agreed upon by the attending physician involved in my care, or by other means or additional health care professionals if required by my state law.

(2) Alternate Health Care Agent
If the person I appoint is unable, unwilling or unavailable to act as my health care agent, or has died, or has divorced from me, I hereby appoint: Julio Aguilar, 3525 Princess Ct., Santee, CA, 90210, (619) 562-8399, as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.

(3) Expiration and Limitations
Unless I revoke it this proxy shall remain in effect indefinitely.

(4) General Instructions
I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows. I have communicated with my agent my wishes regarding artificial nutrition and hydration and give my agent full authority to make decisions regarding artificial nutrition and hydration.

(5) Identification
Name: Robert Fielding
Signature: _________________________________________________
Date: _______________________
Address: 8399 Pebble Beach Santee, CA 90210

(6) Organ and Tissue Donation
I hereby make an anatomical gift, to be effective upon my death of any needed organs, tissues, or parts for the purposes of transplantation only.
Your Signature: _________________________________________________
Date: _____________________

(7) Effect of Copy: A copy of this document has the same effect as the original.

(8) Legal Variations: If, in my state, any instructions on this form cannot be legally followed, all remaining legally valid instructions should still be followed.

(9) Statement by Witnesses
I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence. I am not named above as a health care agent for that person. If the person who signed this document resides outside of New York, I also declare that: I am not the person's health care provider, nor an employee thereof; I am not financially responsible for the person's health care; I am not an employee of any insurance provider for the person; I am not a creditor to the person nor entitled to any portion of the person's estate by way of will or other legal document; I am not related by blood, adoption, or marriage to the person.

Date: __________________ Date: ____________________
Witness:________________ Witness:__________________

(10) Notarization:
I, _________________________, a licensed Notary Public, hereby certify that the principal named above appeared before me and swore to me and to the witnesses in my presence that this instrument is an advance directive document, and that he/she willingly and voluntarily made and executed it as his/her free act and deed for the purposes expressed in it. I further certify that __________________and___________________, witnesses, appeared before me and swore that they witnessed Robert Fielding sign the attached health care power of attorney, believing him/her to be of sound mind; and also swore that at the time they witnessed the signing, they were not related within the third degree to him or his spouse. I further certify that I am satisfied as to the genuineness and due execution of the instrument.
This the _____ day of _____________,20________.
County of_______________________________
State of _______________________________
Notary Public ________________________________________________
My Commission Expires: ______________________________________________

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