MICHIGAN DURABLE POWER OF ATTORNEY FOR HEALTH CARE

I, ________________________________________________ [print or type your full name], am of sound mind, and I voluntarily make this designation.

I designate ________________________________________________, my ____________________________ [insert name of patient advocate spouse, child, friend, etc.], living at ____________________________________________________________________________________ [address of patient advocate] as my patient advocate to make care, custody and medical treatment decisions for me in the event I become unable to participate in medical treatment decisions. If my first choice cannot service, I designate: ________________________________________________ [name of successor], living at ____________________________________________________________________________________ [address of successor] to serve as patient advocate.

The determination of when I am unable to participate in medical treatment decisions shall be made by my attending physician and another physician or licensed psychologist.

In making decisions for me, my patient advocate shall follow my wishes of which he or she is aware, whether expressed orally, in a living will, or in this designation.

My patient advocate has authority to consent to or refuse treatment on my behalf, and to arrange medical services for me, including admission to a hospital or nursing care facility, and to pay for such services with my funds. My patient advocate shall have access to any medical records to which I have a right.

I expressly authorize my patient advocate to make decisions to withhold or withdraw treatment which would allow me to die and I acknowledge such decision could or would allow my death.

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SIGN YOUR NAME HERE IF YOU WISH TO GIVE YOUR PATIENT ADVOCATE THIS AUTHORITY

My specific wishes concerning health care are the following (if none, write "none"):

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

I may change my mind at any time by communicating in any manner that this designation does not reflect my wishes.

It is my intent that my family, the medical facility, and any doctors, nurses and other medical personnel involved in my care shall have no civil or criminal liability for honoring my wishes as expressed in this designation or for implementing the decisions of my patient advocate.

Photostatic copies of this document, after it is signed and witnessed, shall have the same legal force as the original document.

I sign this document after careful consideration. I understand its meaning and I accept its consequences.

Signed this ______ day of _________________, 20_____.

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Signature of Person Making Declaration (Declarant)

__________________________________________
(Type or Print Name of Declarant)

__________________________________________
Street Address

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City                              State                  Zip Code

NOTICE REGARDING WITNESSES

You must have two adult witnesses who will not receive your assets when you die (whether you die with or without a will), and who are not your spouse, child, grandchild, brother or sister, or an employee at the health care facility where you are a patient.

STATEMENT OF WITNESSES

We sign below as witnesses. This declaration was signed in our presence. The declarant appears to be of sound mind, and to be making this designation voluntarily, without duress, fraud or undue influence.

__________________________________________           __________________________________________
Signature of 1st Witness                                                Signature of 2nd Witness

__________________________________________           __________________________________________
(Type or Print Name of Witness)                                      (Type or Print Name of Witness)

__________________________________________           __________________________________________
Street Address                                                              Street Address

__________________________________________           __________________________________________
City                              State                 Zip Code           City                              State                 Zip Code

ACCEPTANCE BY PATIENT ADVOCATE

(A)    This designation shall not become effective unless the patient is unable to participate in treatment decisions.

(B)    A patient advocate shall not exercise powers concerning the patient?s care, custody and medical treatment that the patient, if the patient were able to participate in the decision, could not have exercised on his or her own behalf.

(C)    This designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a patient who is pregnant that would result in the pregnant patient?s death.

(D)    A patient advocate may make a decision to withhold or withdraw treatment, which would allow a patient to die, only if the patient has expressed in a clear and convincing manner that the patient advocate is authorized to make such a decision, and that the patient acknowledges that such a decision could or would allow the patient?s death.

(E)    A patient advocate shall not receive compensation for the performance or his or her authority, rights, and responsibilities, but a patient advocate may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities.

(F)    A patient advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the patient and all act consistent with the patient?s best interest. The known desires of the patient expressed or evidenced while the patient is able to participate in medical treatment decisions are presumed to be in the patient?s best interests.

(G)   A patient may revoke his or her designation at any time or in any manner sufficient to communicate an intent to revoke.

(H)    A patient advocate may revoke his or her acceptance to the designation at any time and in any manner sufficient to communicate an intent to revoke.

(I)       A patient admitted to a health facility or agency has the rights enumerated in Section 20201 of the Public Health Code, Act N. 368 of the Public Acts of 1978, being Section 333.20201 of the Michigan Compiled Laws.

I understand the above conditions, and I accept the designation as patient advocate for: __________________________________________ [insert name of declarant].

Signed this ______ day of _________________, 20_____.

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Signature of Patient Advocate

__________________________________________
(Type or Print Name of Patient Advocate)

__________________________________________
Street Address

__________________________________________
City                              State                 Zip Code

Other Forms You May Need

* Michigan General Durable Power of Attorney for Property & Finances (Immediate)
* HIPAA Authorization and Waiver
click to download Michigan Durable Power Of Attorney For Health Care template
                            

Other legal template form