Issue link: http://viewer.e-digitaledition.com/i/848023
Healthcare directive (day/month/year) cut out (day/month/year) My personal information Name Address Home phone Work phone Date of birth Social Security number I revoke all living wills, durable powers of attorney for health care, or other written advance healthcare directives I have signed in the past. Part 1: Naming an agent Agent duties My healthcare agent can: • Make healthcare decisions for me if I am unable to make and communicate decisions for myself. • Make decisions based on any instructions in part 2 of this document or in other documents. • Make decisions based on what he or she knows about my wishes. • Act in my best interests if instructions are not available. Agent roles When naming your healthcare agent, choose one of the following. Initial the line in front of the statement you want. Act alone I appoint one person to serve as my primary healthcare agent to make decisions for me if I am unable to make or communicate these decisions for myself. My primary agent may act alone. If my primary agent is not able, willing, or available, each alternate agent I name may act alone, in the order listed. Act together I appoint two or more persons to act together as my healthcare agent. My primary agent and alternate agents must act together and be in agreement when making decisions. If they are not all readily available, or if they disagree, a majority of the agents who are readily available may make decisions for me. Purpose of form Part 1 Allows you to appoint another person (called an agent) to make healthcare decisions if a doctor decides you are unable to do so. Part 2 Allows you to give written instructions about what you want. Part 3 Requires you and others to sign and date to make this legal. www.sfcare.org 3