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Attorney Agreement for Injury Collection
Attorney Agreement for Injury Collection I, _________________________, direct __________________________, to pay from the proceeds of any recovery related to or arising out of that incident occurring on _____________________ in which I was injured, such sums as may be due and owing to _______________________ for services which have been rendered or which will be rendered, up […]
Continue reading...Statutory Declaration in Conformance with Florida Life Prolonging Procedure Act, F.S. 765.05
6. December 2008
Statutory Declaration in Conformance with Florida Life Prolonging Procedure Act, F.S. 765.05 DECLARATION OF ________________________ Declaration made this __________ day of _____________ 20________. I ___________ willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare: If at any time I should […]
Continue reading...Statutory Declaration in Conformance with Indiana Living Will and Life-Prolonging Procedures Act, Indiana Code 16-8-11-12
5. December 2008
Statutory Declaration in Conformance with Indiana Living Will and Life-Prolonging Procedures Act, Indiana Code 16-8-11-12 LIVING WILL DECLARATION OF ________________ Declaration made this __________ day of _________________ 20________. I, _____________, being at least eighteen (18) years old and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially […]
Continue reading...Declaration of a Desire for a Natural Death as Provided by North Carolina G.S. 90-321
4. December 2008
Declaration of a Desire for a Natural Death as Provided by North Carolina G.S. 90-321 I, ________________, being of sound mind, desire that my life not be prolonged by extraordinary means if my condition is determined to be terminal and incurable. I am aware and understand that this writing authorizes a physician to withhold or […]
Continue reading...Declaration as Provided by Montana Stats. 50-9-104
2. December 2008
Declaration as Provided by Montana Stats. 50-9-104 DECLARATION If I should have an incurable or irreversible condition that will cause my death within a reasonable short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions […]
Continue reading...Directive to Physicians as Provided by Texas Natural Death Act: Section 3
2. December 2008
Directive to Physicians as Provided by Texas Natural Death Act: Section 3 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, and do hereby declare: 1. If […]
Continue reading...Denial of Medical Insurance Claim, Response
1. December 2008
Denial of Medical Insurance Claim, Response Name Insurance Coverage In: Plan #: Family Name Covered Under Plan: Individual Covered & Subject to This Letter: Social Security Number of Individual: Their Case Number, if one is assigned: Dear Sir or Madam: On ______________ (Date), a claim was filed with you regarding _________________. We received notice, see […]
Continue reading...Living Will as Provided by Georgia Code, Section 31-32-3
1. December 2008
Living Will as Provided by Georgia Code, Section 31-32-3 LIVING WILL Living will made this _________________ day of ___________. I _______________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be prolonged under the circumstances set forth below, and do declare: 1. If at any time I should […]
Continue reading...Declaration as Provided by Maryland Health-General Code Section 5-602
30. November 2008
Declaration as Provided by Maryland Health-General Code Section 5-602 DECLARATION On this _________________ day of ___________, I ________ ______, being of sound mind, willfully and voluntarily direct that my dying shall not be artificially prolonged under the circumstances set forth in this declaration: If at any time I should have an incurable injury, disease, or […]
Continue reading...Declaration as Provided by Hawaii Revised Statutes Chapter 327D, Section 4 DECLARATION
30. November 2008
Declaration as Provided by Hawaii Revised Statutes Chapter 327D, Section 4 DECLARATION A. Statement of Declarant Declaration made this __________________ day of _____________, 20_______. I, _________________ being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare: […]
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7. December 2008
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