Sie sind auf Seite 1von 4

INFORMATION ABOUT THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT.

BEFORE SIGNING THIS DOCUMENT IT IS VITAL FOR YOU TO KNOW AND UNDERSTAND THESE FACTS: THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR ATTORNEY-IN-FACT THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU CANNOT MAKE THE DECISIONS FOR YOURSELF. AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE HEALTH CARE DECISIONS FOR YOURSELF IF YOU ARE MENTALLY COMPETENT TO DO SO. IN ADDITION, AFTER YOU HAVE SIGNED THIS DOCUMENT, NO TREATMENT MAY BE GIVEN TO YOU OR STOPPED OVER YOUR OBJECTION IF YOU ARE MENTALLY COMPETENT TO MAKE THAT DECISION. YOU MAY STATE IN THIS DOCUMENT ANY TYPE OF TREATMENT THAT YOU DO NOT DESIRE AND ANY THAT YOU WANT TO MAKE SURE YOU RECEIVE. YOU HAVE THE RIGHT TO TAKE AWAY THE AUTHORITY OF YOUR ATTORNEYIN-FACT UNLESS YOU HAVE BEEN ADJUDICATED INCOMPETENT, BY NOTIFYING YOUR ATTORNEY-IN-FACT OR HEALTH CARE PROVIDER EITHER ORALLY OR IN WRITING. SHOULD YOU REVOKE THE AUTHORITY OF YOUR ATTORNEY-IN-FACT, IT IS ADVISABLE TO REVOKE IN WRITING AND TO PLACE COPIES OF THE REVOCATION WHEREVER THIS DOCUMENT IS LOCATED. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A SOCIAL WORKER, LAWYER, OR OTHER PERSON TO EXPLAIN IT TO YOU. YOU SHOULD KEEP A COPY OF THIS DOCUMENT AFTER YOU HAVE SIGNED IT. GIVE A COPY TO THE PERSON YOU NAME AS YOUR ATTORNEY-IN-FACT. IF YOU ARE IN A HEALTH CARE FACILITY, A COPY OF THIS DOCUMENT SHOULD BE INCLUDED IN YOUR MEDICAL RECORD.

DECLARATION and POWER OF ATTORNEY FOR HEALTH CARE I. DECLARATION


Declaration made this _____ day of ____________________, _____. A. LIFE-SUSTAINING PROCEDURES. I, Dorian Mayhew Rothschild being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged
This is a RocketLawyer.com Legal Document

under the circumstances set forth below, do declare: If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition or a permanently unconscious condition, by 2 physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized, or that I will remain in a permanently unconscious condition, and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

II. POWER OF ATTORNEY FOR HEALTH CARE


A. DESIGNATION OF HEALTH CARE ATTORNEY-IN-FACT. I, Dorian Mayhew Rothschild, of the District of Columbia, hereby appoint (Your health care provider may not be named as the Attorney-in-Fact.): Attorney-in-Fact: Maria L. Rothschild Address: Phone: Relation, if any: 35 Palm Circle Dr. Corte Madera, CA 95422 Home: 4157745543 Work: 4157745543 Daughter

as my Attorney-in-Fact (Agent) to make health care decisions for me if I become unable to make my own health care decisions. This gives my Attorney-in-Fact the power to grant, refuse, or withdraw consent on my behalf for any health care service, treatment or procedure. My Attorneyin-Fact also has the authority to talk to health care personnel, get information and sign forms necessary to carry out these decisions. B. CREATION OF POWER OF ATTORNEY FOR HEALTH CARE. With this document, I intend to create a Power of Attorney for Health Care, which shall take effect if I become incapable of making my own health care decisions and shall continue during that incapacity. C. RIGHTS AND DUTIES OF ATTORNEY-IN-FACT. Subject to any express limitations in this document, my Attorney-in-Fact shall have all the rights, powers and authority related to health care decisions that I would have under District and federal law, including the authority to direct the withdrawal and withholding of artificially provided food and fluids. This authority shall include, at a minimum: (a) The authority to grant, refuse or withdraw consent to the provision of any health care service, treatment or procedure; (b) The right to review my health care records; (c) The right to be provided with all information necessary to make informed health care decisions;
This is a RocketLawyer.com Legal Document

(d) The authority to select and discharge health care professionals; and (e) The authority to make decisions regarding admission to or discharge from health care facilities and to take any lawful actions that may be necessary to carry out these decisions. My Attorney-in-Fact shall make health care decisions as I direct below or as I make known to my Attorney-in-Fact in some other way. D. DESIGNATION OF ALTERNATE ATTORNEY-IN-FACT. If the person designated as my Attorney-in-Fact is not available or unable to act, I designate the following persons to serve as my Attorney-in-Fact to make health care decisions for me as authorized by this document, who serve in the following order: FIRST ALTERNATE ATTORNEY-IN-FACT Attorney-in-Fact: David D. Rothschild Address: Phone: 89 Bark St. San Francisco, CA 94103 Home: 4157750453 Work: 4158854455

III. GENERAL PROVISIONS


A. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them. B. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable. C. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions. BY MY SIGNATURE I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT AND AM EMOTIONALLY AND MENTALLY COMPETENT TO MAKE THIS DECLARATION. I sign my name to this form on the _____ day of ____________________, _____, in the District of Columbia.

This is a RocketLawyer.com Legal Document

Signature: Name: SSN: Birthdate:

________________________________________ Dorian Mayhew Rothschild District of Columbia 123-45-6789 April 17, 1963 STATEMENT OF WITNESSES

I declare that Dorian Mayhew Rothschild, who signed or acknowledged this document in my presence, is personally known to me. I believe Dorian Mayhew Rothschild to be of sound mind and under no duress, fraud, or undue influence. I am at least eighteen (18) years of age. I did not sign Dorian Mayhew Rothschild's signature above for or at the direction of Dorian Mayhew Rothschild. I am not directly financially responsible for Dorian Mayhew Rothschild's medical care. I am not Dorian Mayhew Rothschild's attending physician or health care provider, an employee of the attending physician or health care provider, or an employee of the health facility in which Dorian Mayhew Rothschild is a patient. I am not the person appointed as the Attorney-in-Fact by this document. I am not related to Dorian Mayhew Rothschild by blood, marriage, or adoption. To the best of my knowledge, I am not entitled to any part of the estate of Dorian Mayhew Rothschild under a currently existing will or codicil or by operation of law, including the laws of Intestate Succession of the District of Columbia.

Witness Signature: Name: Address:

________________________________________ Alex R. Olsen 123 Main St. Mill Valley, CA 94941

Date: _________________________

Witness Signature: Name: Address:

________________________________________ Bill Venson 440 Montgomery St. San Francisco, CA 94103

Date: _________________________

This is a RocketLawyer.com Legal Document