Beruflich Dokumente
Kultur Dokumente
Under Virginia State Law
This document will be valid after you and your witnesses sign it. However, your healthcare Agent and
any alternates must receive a copy of this document and sign and date the section below titled Agent
Acknowledgment and Acceptance in order to accept his or her responsibilities before making any
decisions on your behalf.
SECTION 1.
APPOINTMENT OF HEALTHCARE AGENT
I, H Allen TaylorII, the "Principal," appoint the following person as my healthcare "Agent" (which
includes within its meaning a healthcare 'proxy,' 'surrogate,' 'representative,' 'executor,' or 'patient
advocate' in jurisdictions that so require, as well as any Successor Agents) to make healthcare decisions
on my behalf and to have the authority specified herein. I have notified the Agent and the successors
listed below (the "Successor Agents") of my wishes concerning health care. I appoint the following
individual as my healthcare Agent:
Agent: Wanda BynumTaylor
Relationship: Spouse
Address: 102 Oakmont Circle
Williamsburg, Virginia 23185
Phone Number: 7577198510
If my Agent is not willing, unavailable, or otherwise unable to serve for me, I appoint the following
individual as my first Successor Agent:
Successor Agent: Jakeya R Bynum
Relationship: Daugther
Address: 102 Oakmont Circle
Williamsburg, Virginia 23185
Phone Number: 7575615766
Agent's Authority. My Agent named herein is authorized to make any and all healthcare decisions for
me, except as otherwise limited by this document. This is a durable power of attorney, and, as such,
my Agent's authority will begin when I become incapacitated or am otherwise unable to make
decisions for myself, as determined by a physician. My Agent's authority will continue until properly
revoked or terminated in accordance herewith. Without limitation and unless otherwise stated herein,
this authority shall include the authority to:
b. authorize, or refuse to authorize, any medication or procedure intended to relieve pain, even
though such use may lead to physical damage, addiction, or hasten the moment of, but not
intentionally cause, my death;
c. refuse, consent, or revoke consent to any and all types of medical care, treatments, surgical
procedures, diagnostic procedures, medication, and the use of mechanical or other procedures
that affect any bodily function, including, but not limited to, artificial respiration, nutrition and
hydration, and cardiopulmonary resuscitation; and
a. take any other action necessary for documenting and assuring implementation of my healthcare
decisions, including, without limitation, granting any waiver or release from liability required
by any hospital, physician, nursing care provider, or other healthcare provider; signing any
documents relating to refusals of treatment or my leaving a facility against medical advice; and
pursuing any legal action in my name, and at the expense of my estate, to force compliance with
my wishes as determined by my Agent, or to seek actual or punitive damages for the failure to
comply.
Unless my wishes on the subject are already known, I direct my Agent to attempt to consult with me to
determine my wishes concerning any healthcare decision if I am able to communicate in any way,
including the ability to blink. To the extent my wishes are unknown, my Agent shall make healthcare
decisions for me in accordance with what he or she determines to be in my best interest. In determining
my best interest, my Agent shall consider my personal values to the extent known to him or her and
may consult any of my known friends and family members to help inform his or her judgment.
My Agent may accompany me in an ambulance or air ambulance if, in the opinion of the ambulance
personnel, protocol permits a passenger, and my Agent may visit or consult with me in person while I
am in a hospital, skilled nursing facility, hospice, or other healthcare facility or service if its protocol
permits visitation.
(INITIAL IF APPLICABLE)
____ I expressly authorize my Agent to direct the withholding or withdrawal of artificial nutrition or
hydration and all other forms of health care to keep me alive. I do not want my life to be prolonged, nor
do I want lifesustaining or deathdelaying treatment to be provided or continued if my Agent believes
the burdens of the treatment outweigh the expected benefits.
_____ I do not wish to be resuscitated in the event that my quality of life would be so impaired that I
would be miserable or it would be a tremendous financial or emotional burden to my family or loved
ones. In such a situation, I would only want to live if my Agent believes the expected benefit of the
treatment outweighs the burden. Decisions concerning life support are to be made in consensus with
any doctors or other healthcare professionals.
Medical Release and HIPAA Waiver of Confidentiality for My Agent (Optional)
(INITIAL)
____ I authorize my Agent to exercise all my rights regarding the use and disclosure of my individually
identifiable health information or other medical records, including, without limitation, the following:
(a) requesting, reviewing, and receiving any information, verbal or written, regarding my physical or
mental health, including, but not limited to, medical and hospital records, insurance, and financial and
other information related to any past, present, or future physical or mental health condition, including
information related to sexually transmitted diseases, HIV/AIDs, mental illness, and substance abuse;
and (b) any written or oral opinions of my physician or healthcare provider concerning such
information. My Agent may also execute on my behalf any releases or other documents that may be
required in order to obtain this information and consent to the disclosure of this information. This
medical release applies to any information governed by the Health Insurance Portability and
Accountability Act of 1996 (a.k.a. HIPAA), 42 USC 1320d and 45 CFR 160164.
SECTION 2.
NOMINATION OF A GUARDIAN OR CONSERVATOR
If a guardian or conservator of my person needs to be appointed for me by a court:
(INITIAL)
____ I nominate the Agent designated in this form as my first choice. If the Agent is not willing, able,
or reasonably available to act as guardian or conservator, I nominate the Successor Agent(s) named
above, in the order so designated.
SECTION 3.
AUTOPSY
Filling out this section is optional. If you so choose to fill out this section, initial only one of the
following: (INITIAL ONE)
_____ I do not consent to an autopsy in any situation unless otherwise required by law.
_____ I consent to an autopsy.
_____ I authorize my Agent to decide whether I am to be autopsied.
SECTION 4.
FUNERAL AND BURIAL WISHES (OPTIONAL)
My wishes concerning the disposition of my remains are as follows. Upon my death: (INITIAL ALL
THAT APPLY)
_____ I authorize my Agent to administer all aspects of my funeral and burial wishes.
_____ I do NOT wish to have my remains cremated.
SECTION 5.
PHYSICIAN AFFIDAVIT (OPTIONAL)
You have the option of consulting a physician before initialing any choice in this document. If you do
consult a physician, it is recommended that you have him or her complete this affidavit and give the
physician a copy to keep.
I agreed to comply with the provisions of this directive.
Physician's Signature: ____________________________________
Physician's Address: ____________________________________
_____________________________________________________
Date: _______________________
SECTION 6.
GENERAL PROVISIONS
Effective Date. This document will be effective when signed, and my Agent's authority to make
healthcare decisions on my behalf will begin when I become incapacitated or am otherwise unable to
make decisions for myself, as determined by a physician.
(INITIAL)
____ Except in the case of mental illness, my Agent's authority becomes effective when my primary
physician determines that I am unable to make my own healthcare decisions. In the case of mental
illness, my Agent's authority becomes effective when a court determines I am unable to make my own
decisions, or, in an emergency, if my primary physician or another healthcare provider determines I am
unable to make my own decisions.
Duration and Revocation. The authority of my Agent, when effective, shall not terminate or be void
or voidable if I am or become disabled or in the event of later uncertainty as to whether I am dead or
alive. I understand that this Power of Attorney exists indefinitely from the date I execute this document
unless I revoke it or establish a shorter time or revoke the Power of Attorney. The authority I have
granted my Agent continues to exist until the time I become able to make healthcare decisions for
myself. Any time while I am competent, I may revoke this Power of Attorney in a writing I sign or by
communicating my intent to revoke, in any clear and consistent manner, to my Agent or my healthcare
provider. By executing this instrument I revoke any prior healthcare power of attorney.
Amendment. I retain the right to revoke or amend this Power of Attorney and to substitute other agents
in place of my Agent. Amendments to this Power of Attorney must be made in writing by me
personally. They must be attached to the original of this document and, if the original is recorded, must
be recorded in the same county or counties as the original, although failure to record any amendment
will not alter its affect.
Jurisdiction, Severability, and Durability. This instrument is intended to be valid in any jurisdiction
in which it is presented. The powers delegated herein are severable, so that the invalidity of one or
more powers or provisions shall not affect the validity of any others. This Power of Attorney shall not
be affected or revoked by my incapacity or mental incompetence.
Reliance of Third Parties on Healthcare Agent. No person who relies in good faith upon the
authority of or any representations by my Agent shall be liable to me, my estate, my heirs, successors,
assigns, or personal representatives for actions or omissions in reliance on that authority or those
representations.
The powers conferred on my Agent by this document may be exercised by my Agent alone, and my
Agent's signature or action taken under the authority granted in this document may be accepted by
persons as fully authorized by me and with the same force and effect as if I were personally present,
competent, and acting on my own behalf. All acts performed in good faith by my Agent pursuant to this
Power of Attorney are done with my consent and shall have the same validity and effect as if I were
present and exercised the powers myself, and shall inure to the benefit of and bind me, my estate, my
heirs, successors, assigns, and personal representatives. The authority of my Agent pursuant to this
Power of Attorney shall be superior to and binding upon my family, relatives, friends, and others.
Ratification. I ratify and confirm all that my Agent does or causes to be done under the authority
granted in this instrument. All contracts, promissory notes, checks, or other bills of exchange, drafts,
other obligations, instruments, and other documents signed, endorsed, drawn, accepted, made,
executed, or delivered by my Agent will bind me, my estate, my heirs, successors, and assigns.
Signature of Agent. My Agent must use the following form when signing on my behalf pursuant to
this Power of Attorney: [Principal Name] by [Agent Name], Agent.
Governing Law. This instrument is executed under and shall be construed according to the laws of
Virginia.
Reliance on this Power of Attorney. Any person, including my Agent, may act in reliance upon the
validity of this Power of Attorney or a copy of it unless that person knows it has terminated or is no
longer valid.
Original Copy. The fully executed original copy of this Power of Attorney is in the possession of my
Agent.
SECTION 7.
AGENT ACKNOWLEDGMENT AND ACCEPTANCE
1. This Agent designation is not effective unless the Principal is unable to participate in decisions
regarding the Principals medical or mental health, as applicable. If this Agent designation
includes the authority to make an anatomical gift, the authority remains exercisable after the
Principal's death.
2. The Agent shall not exercise powers concerning the Principal's care, custody, and medical or
mental health treatment that the Principal, if the Principal were able to participate in the
decision, could not have exercised on his or her own behalf.
3. This Agent designation cannot be used to make a medical treatment decision to withhold or
withdraw treatment from a Principal who is pregnant if that would result in the pregnant
Principal's death.
4. The Agent may make a decision to withhold or withdraw treatment that would allow a Principal
to die only if the Principal has expressed in a clear and convincing manner that the Agent is
authorized to make such a decision, and that the Principal acknowledges that such a decision
could or would allow the Principal's death.
5. The Agent shall not receive compensation for the performance of his or her authority, rights,
and responsibilities, but the Agent may be reimbursed for actual and necessary expenses
incurred in the performance of his or her authority, rights, and responsibilities.
6. The Agent shall act in accordance with the standards of care applicable to fiduciaries when
acting for the Principal and shall act consistent with the Principal's best interests. The known
desires of the Principal expressed or evidenced while the Principal is able to participate in
medical or mental health treatment decisions are presumed to be in the Principal's best interests.
7. The Principal may revoke his or her Agent designation at any time and in any manner sufficient
to communicate intent to revoke.
8. The Principal may waive his or her right to revoke the Agent designation as to the power to
make mental health treatment decisions, and if such a waiver is made, his or her ability to
revoke as to certain treatment will be delayed for 30 days after the Principal communicates his
or her intent to revoke.
9. The Agent may revoke his or her acceptance of the Agent designation at any time and in any
manner sufficient to communicate intent to revoke.
Agent. I, Wanda BynumTaylor, understand the above terms, conditions, and responsibilities and am
willing to serve as the healthcare Agent for the named Principal.
Signature: ________________________________________
Date: _________________________
Successor Agent. I, Jakeya R Bynum, understand the above terms, conditions, and responsibilities and
am willing to serve as the healthcare Agent for the named Principal if the first Agent cannot serve.
Signature: ________________________________________
Date: _________________________
SECTION 8.
MY SIGNATURE
I sign this healthcare power of attorney voluntarily. I understand the choices I have made, I am under
no duress to sign this, and declare that I am emotionally and mentally competent at this time. I am
signing this in the presence of a notary public and/or the appropriate number of witnesses as required
by state law.
Your Name: H Allen TaylorII
Address: 102 Oakmont Circle
Williamsburg, Virginia 23185
Phone Number(s): 7572200762
Date of Birth: November 28, 1954
SSN or TIN: __________________________
Your Signature: ____________________________________________________
Date Signed: __________________________
SECTION 9.
WITNESSES
Name of first witness: ___________________________________
Signature: _____________________________________________
Address of witness: _____________________________________
___________________________________________
Date: _______________________
Name of second witness: _________________________________
Signature: _____________________________________________
Address of witness: _____________________________________
___________________________________________
Date: _________________________
Note: If the Principal is physically unable to sign, each witness must also sign the following
statement:
The Principal has directly indicated to me that this healthcare power of attorney expresses his or her
wishes and that the Principal intends to adopt this document at this time.
Witness: ______________________________ Date: _____________
Witness: ______________________________ Date: _____________
SECTION 10.
NOTARY ACKNOWLEDGMENT
State of Virginia
County of ____________________________
On _____________ (date), before me, _____________________________ (notary), appeared H Allen
TaylorII, personally known to me (or proved to me on the basis of satisfactory evidence), and of sound
mind and free from duress, to be the person(s) whose name(s) is/are subscribed to the within medical
power of attorney and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or entity
upon behalf of which the person(s) acted, executed the instrument. Furthermore, I am not the person
the individual appointed as his or her Agent or Successor Agent.
I certify under PENALTY OF PERJURY that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Print: ____________________________ Commission Expires: _______________
Sign: ____________________________ [Affix seal]
NOTARY PUBLIC
Note: If the Principal is physically unable to sign, the notary must also sign the following statement:
The Principal has directly indicated to me that this healthcare power of attorney expresses his or her
wishes and that the Principal intends to adopt this document at this time.
Notary: ______________________________ Date: _____________
Instructions for Your Medical Power of Attorney
Use the LegalNature medical power of attorney to designate someone you trust to make important
healthcare decisions on your behalf. It is important to have a medical power of attorney if you have
been diagnosed with a serious illness. Even if you are still healthy now, it is smart to protect yourself in
case something should happen to you.
In your state, this person may be called your agent, proxy, representative, or something similar. Your
agent is legally required to follow your directions listed in the document as well as any other wishes
you communicate to him or her. You can also use our living will form, which includes a healthcare
power of attorney in it, to specify your wishes concerning treatment you receive when you become too
sick to speak for yourself.
Your healthcare agent needs to be at least 18 years old and mentally competent to follow your
directions. In addition, read your document for any additional statespecific requirements. Many states
prevent you from appointing your physician or an employee of your healthcare provider as your agent.
If you are unsure, it is best to appoint someone who does not fall into these categories and is someone
you trust to carry out your wishes no matter what.
In addition, the LegalNature healthcare power of attorney allows you the option to appoint a guardian
of your person or estate should you need one. You can also elect to designate your primary physician
and your wishes concerning organ donation and burial.
Executing Your Medical Power of Attorney
It is very important that you read the ENTIRE document before signing. Not only are you delegating
important authority to your agent that you need to be aware of, but there are many places that require
you to initial next to your choices. Initialing is required to both indicate your choice and to prove your
wishes in the event there is ever a dispute. Once you are sure you have read the document and indicated
your healthcare choices, simply sign and date where applicable and follow the witnessing requirements
below.
Witnessing Requirements
In Virginia, at least two witnesses must sign. However, it is best (and we recommend) to have two
disinterested witnesses AND a notary sign your power of attorney. This will help verify the authenticity
of the document should there ever be a question.