Attorney
- Submitted by: lanced
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- Category: Other
- Date Submitted: 02/15/2013 08:49 AM
- Pages: 3
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DESIGNATION OF
HEALTH CARE SURROGATE
I, _________________, domiciled in_____________________, hereby designate _________, as my health care surrogate to make any health care decisions for me when I no longer have decisional capacity. Any prior designation is revoked.
If, at any time, it appears that I am unable to care for myself and that it is appropriate that I be placed in a long-term facility, before placing me in such a facility, my health care surrogate shall obtain statements from my attending and one (1) other physician to the effect that, in their professional medical opinions, the condition of my health is of the nature and duration that I should be placed in a long-term care facility which is certified to administer the proper care over my health. If my attending and one (1) other physician, in their professional medical opinions, thereafter make a determination that the condition of my health has improved so that I can care for myself, then, in such event, my health care surrogate shall assist me in being removed from the long-term care facility and returned to a residential setting.
In addition to the rights given my health care surrogate above, I grant my health care surrogate the follows:
1. My health care surrogate shall have the ability to control and provide for my personal care needs as follows:
(a) To do all acts to maintain my customary standard of living, to provide for my living place through purchase, lease or other method, to provide domestic help with either skilled or non-skilled help and to compensate, hire and dismiss such person;
(b) To provide for me opportunities for recreation, physical exercise, therapy and to arrange travel in accordance with such needs;
(c) To provide for my spiritual care; and
(d) To take care of my person in case of sickness or disability of any kind, including the removal of or placement in any such institution or place as may be deemed best by my health care surrogate...
HEALTH CARE SURROGATE
I, _________________, domiciled in_____________________, hereby designate _________, as my health care surrogate to make any health care decisions for me when I no longer have decisional capacity. Any prior designation is revoked.
If, at any time, it appears that I am unable to care for myself and that it is appropriate that I be placed in a long-term facility, before placing me in such a facility, my health care surrogate shall obtain statements from my attending and one (1) other physician to the effect that, in their professional medical opinions, the condition of my health is of the nature and duration that I should be placed in a long-term care facility which is certified to administer the proper care over my health. If my attending and one (1) other physician, in their professional medical opinions, thereafter make a determination that the condition of my health has improved so that I can care for myself, then, in such event, my health care surrogate shall assist me in being removed from the long-term care facility and returned to a residential setting.
In addition to the rights given my health care surrogate above, I grant my health care surrogate the follows:
1. My health care surrogate shall have the ability to control and provide for my personal care needs as follows:
(a) To do all acts to maintain my customary standard of living, to provide for my living place through purchase, lease or other method, to provide domestic help with either skilled or non-skilled help and to compensate, hire and dismiss such person;
(b) To provide for me opportunities for recreation, physical exercise, therapy and to arrange travel in accordance with such needs;
(c) To provide for my spiritual care; and
(d) To take care of my person in case of sickness or disability of any kind, including the removal of or placement in any such institution or place as may be deemed best by my health care surrogate...