Living Will as Provided by Tennessee Code 32-11-105 LIVING WILL OF ___________________ I, ____________, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare: If at any time I should have a terminal condition and my attending physician has determined […]
Continue reading...21. November 2008
Statutory Declaration in Conformance with Kansas Natural Death Act, Kansas Statutes Section 65-28,103 DECLARATION OF ___________________ 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, do hereby declare: If […]
Continue reading...20. November 2008
Declaration of Intention Provided by Mississippi Withdrawal of Life Saving Mechanisms Act, Mississippi Code 41-41-107 DECLARATION made on ___________ by ___________________ of ____________, _______________. I, ________________, being of sound mind, declare that if at any time I should suffer a terminal physical condition which causes me severe distress or unconsciousness, and my physician, with the […]
Continue reading...19. November 2008
Statutory Declaration in Conformance with New Hampshire Terminal Care Document Law, N.H. R.S. 137-H: 3 DECLARATION OF ___________________ Declaration made this __________ day of ________________ 20____. I ________________, being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby […]
Continue reading...18. November 2008
Declaration Provided by Colorado Medical Treatment Decision Act: Colorado Statutes 15-18-104 DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT I _____________, being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that: 1. If at any time […]
Continue reading...17. November 2008
Declaration as Provided by Iowa Code 144A.3 DECLARATION OF __________________ If I should have an incurable or irreversible condition that will cause my death within a relatively 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 […]
Continue reading...17. November 2008
Directive to Physicians as Provided by Idaho Natural Death Act, Idaho Code Section 39-4504 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 below: 1. In the absence of my […]
Continue reading...17. November 2008
Statutory Declaration in Conformance with District of Columbia Natural Death Act of 1981, D.C. Code Section 6-2422 DECLARATION OF __________________ Declaration made this __________ day of ________________ 20________. I, ________________, being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, […]
Continue reading...11. November 2008
Referral Request, for Patient Name Insurance Coverage In: Plan #: Family Name Covered Under Plan: Individual Covered & Subject to This Letter: Social Security Number of Individual: Dear _______________ (Your Physician) The purpose of this letter is to obtain a referral to a specialist. I am seeking your approval for that referral. If possible I […]
Continue reading...11. November 2008
Statutory Declaration in Conformance with Arizona Medical Treatment Decision Act, AZ. REV. STAT. 36-3202 DECLARATION OF __________________ Declaration made this __________ day of ________________ 20________. I, ______________, being of sound mind, willfully and artificially prolonged under the circumstances set forth below and declare that: If at any time I should have an incurable injury, disease, […]
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21. November 2008
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