ADVANCE DIRECTIVE I. APPOINTMENT OF HEALTH CARE AGENT.

I, Dorian Mayhew Rothschild, born December 11, 1957 of Rosterdale, Maryland, appoint: Agent Name: Address: Phone: Relation, if any: Ryan B. Jagger 35 Palm Circle Dr. Rosterdale, MD 85833 Home: (456) 654-1567 Work: (456) 867-1887 Friend

as my Agent to make health care decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document. NOTICE: An owner, operator, or employee of a health care facility from which the Declarant is receiving health care may not serve as a health care agent unless such person has a close connection with the patient. 1. Appointed as guardian for the patient; 2. The patient's spouse; 3. An adult child of the patient; 4. A parent of the patient; 5. An adult sibling of the patient; or 6. A friend or other relative who is a competent individual, and presents an affidavit to the attending physician stating specific facts and circumstances which demonstrate that the person has maintained regular contact with the patient sufficient to be familiar with the patient's activities, health and personal beliefs. A. STATEMENT OF AUTHORITY GRANTED. Subject to any provisions or limitations in this document, I grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, including the power to: a. Employ and discharge my health care providers; b. Authorize my admission to or discharge from (including transfer to another facility) any hospital, hospice, nursing home, adult home, or other medical care facility; and c. Consent to the provision, withholding, or withdrawal of health care, including, in appropriate circumstances, life-sustaining procedures; d. Ride with me in an ambulance if ever I need to be rushed to the hospital; e. Be able to visit me if I am in a hospital or any other health care facility. My agent is to make health care decisions for me based on the health care instructions I give in this document and on my wishes as otherwise known to my agent. If my wishes are unknown or
© This is a RocketLawyer.com Legal Document ©

unclear, my agent is to make health care decisions for me in accordance with my best interest, to be determined by my agent after considering the benefits, burdens, and risks that might result from a given treatment or course of treatment, or from the withholding or withdrawal of a treatment or course of action. My agent shall not be liable for the costs of care based solely on this authorization. B. ACCESS TO MY HEALTH INFORMATION - FEDERAL PRIVACY LAW (HIPPA) AUTHORIZATION a. If, prior to the time the person selected as my agent has power to act under this document, my doctor wants to discuss with that person my capacity to make my own health care decisions, I authorize my doctor to disclose protected health information which relates to that issue. b. Once my agent has full power to act under this document, my agent may request, receive, and review any information, oral or written, regarding my physical or mental health, including, but not limited to, medical and hospital records and other protected health information, and consent to disclosure of this information. c. For all purposes related to this document, my agent is my personal representative under the Health Insurance Portability and Accountability Act (HIPAA). My agent may sign, as my personal representative, any release forms or other HIPAA-related materials. C. EFFECTIVE. My agent's authority becomes effective when my attending physician and a second physician determine that I am incapable of making an informed decision regarding my health care. D. NOMINATION OF GUARDIAN. If a Guardian of my person is to be appointed for me, I nominate Name: Address: Mary Rothschild 60 Arthur St. Rosterdale, MD 85833

to serve as my Guardian.

II. TREATMENT PREFERENCES ("LIVING WILL"). (Initial all that
apply.) If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions as set forth below. A. TERMINAL CONDITION

© This is a RocketLawyer.com Legal Document ©

If my death from a TERMINAL CONDITION is imminent and even if life-sustaining procedures are used there is no reasonable expectation of my recovery: ______ Try to extend my life for as long as possible, using all available interventions that in reasonable medical judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive nutrition and fluids by tube or other medical means. B. PERSISTENT VEGETATIVE STATE If I am in a PERSISTENT VEGETATIVE STATE, that is, if I am not conscious and am not aware of my environment or able to interact with others, and there is no reasonable expectation of my recovery: ______ Try to extend my life for as long as possible, using all available interventions that in reasonable medical judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive nutrition and fluids by tube or other medical means. C. END-STAGE CONDITION If I have an END-STAGE CONDITION, that is a condition caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective: ______ Try to extend my life for as long as possible, using all available interventions that in reasonable medical judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive nutrition and fluids by tube or other medical means. D. PAIN RELIEF ______ I direct that no matter what my condition, medication not be given to me to relieve pain and suffering, if it would shorten my remaining life. E. MEDICAL TREATMENT ______ I direct that no matter what my condition, I be given all available medical treatment in accordance with accepted health care standards. F. EFFECT OF STATEMENT OF PREFERENCES ______ I realize I cannot foresee everything that might happen after I can no longer decide for myself. My stated preferences are meant to guide whoever is making decisions on my behalf and my health care providers, but I authorize them to be flexible in applying these statements if they feel that doing so would be in my best interest.

© This is a RocketLawyer.com Legal Document ©

III. GENERAL PROVISIONS.
A. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them. B. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable. C. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions. (YOU MUST DATE AND SIGN THIS DOCUMENT IN THE PRESENCE OF TWO WITNESSES) By signing below, I indicate that I am emotionally and mentally competent to make this Advance Directive and that I understand the purpose and effect of this document. I also understand that this document replaces any similar advance directive I may have completed before this date. Signed on _____ day of _______________, _____.

Signature: Name: Address:

________________________________________ Dorian Mayhew Rothschild Rosterdale Herron County Maryland 123-45-6789

SSN:

© This is a RocketLawyer.com Legal Document ©

STATEMENT OF WITNESSES Dorian Mayhew Rothschild signed or acknowledged signing this Advance Directive in my presence and based upon my personal observation Dorian Mayhew Rothschild appears to be a competent individual. I am not the person appointed as the Health Care Agent or Alternate Health Care Agent by this document. I further declare that to the best of my knowledge, I am not entitled to any portion of the estate of Dorian Mayhew Rothschild or entitled to any financial benefit by reason of the death of Dorian Mayhew Rothschild.

Witness Signature: Name: Address:

________________________________________ Peter R. Olsen 123 Main St. Champs, MD 85815

Date: _________________________

Witness Signature: Name: Address:

________________________________________ Maria Pedula 440 Montgomery St. Rosterdale, MD 85833

Date: _________________________

© This is a RocketLawyer.com Legal Document ©

Sign up to vote on this title
UsefulNot useful