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Durable Power of Attorney for Health Care
Durable Power of Attorney for Health Care Declaration of a Durable Power of Attorney for Health Care Only 1. Declaration. A. Life Sustaining Procedures. Declaration made on this date, _________, I, ________ (“Declarant”), being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances […]
Continue reading...Authorization to Release Medical Records, Cover Letter
18. December 2008
Authorization to Release Medical Records, Cover Letter Name Insurance Coverage In: Plan #: Family Name Covered Under Plan: Individual Covered & Subject to This Letter: Social Security Number of Individual: To: Medical Office Manager I am writing to request a copy of my medical records. Please send it to me at the address on this […]
Continue reading...Authorization for Release of Medical Records
18. December 2008
Authorization for Release of Medical Records _________________ (“Patient”) of __________________________________(Address), with Social Security Number ___________________, hereby authorizes the release, disclose, and delivery of the medical information described below to: _______________ (Authorized Recipient). Specific Authorization. I specifically authorize the release of all medical information relating to the above-named patient including but not limited to the following […]
Continue reading...Declaration in Conformance with Missouri Statutes 459.015
17. December 2008
Declaration in Conformance with Missouri Statutes 459.015 I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be […]
Continue reading...Directive to Physicians as Provided by the California Health and Safety Code: Section 7187
16. December 2008
Directive to Physicians as Provided by the California Health and Safety Code: Section 7187 DIRECTIVE TO PHYSICIANS Directive made this _________________ day of ___________. I, __________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, do hereby declare: 1. […]
Continue reading...Uniform Living Will (General)
14. December 2008
UNIFORM LIVING WILL OF ________________________________ To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to be. To any individual who may become responsible for my health, welfare or affairs. Death is as much a reality as birth, growth, maturity and old age — it is the […]
Continue reading...Statutory Declaration in Conformance with Illinois Natural Death Act
12. December 2008
Statutory Declaration in Conformance with Illinois Natural Death Act, IL. Stat. 110 ½ Paragraph 703 DECLARATION OF ______________________ This declaration is made this __________ day of __________ 20___________. I, _____________________________, being of sound mind, willfully and voluntarily make known my desires that my moment of death shall not be artificially postponed. If at any time […]
Continue reading...Revocation of Health Care Durable Power of Attorney
11. December 2008
Revocation of Health Care Durable Power of Attorney I, __________________, (“Declarant”), of ____________________________________ (Address), do hereby revoke any and all power and authority granted to my physician, health care provider, or health care agent in the past, but especially the previous Health Care Durable Power Attorney attached in Exhibit 1, and dated _________________, appointing ________________________ […]
Continue reading...Revocation of Previous Living Will and Medical Care Restrictions
10. December 2008
Revocation of Previous Living Will and Medical Care Restrictions I, ________________, desire to make aware that after mature reflection, and, being aware of the right under the law to decline life- sustaining treatment, that I wish, should I ever be unable to make decisions for myself concerning my medical treatment that I receive life sustaining […]
Continue reading...Directive to Physicians as Provided by Nevada Revised Statutes, Section 449.610
8. December 2008
Directive to Physicians as Provided by Nevada Revised Statutes, Section 449.610 DIRECTIVE TO PHYSICIANS Date __________________ I, _______________, being of sound mind, intentionally and voluntarily declare: 1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining […]
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12. March 2009
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