[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"page-\u002Fcategories\u002Fhealthcare\u002Fhealthcare-proxy":3},{"type":4,"data":5},"product",{"product_name":6,"slug":7,"category_slug":8,"order_type":9,"product_version_slug":10,"preview":11,"is_previewable":12,"related_products":13,"related_articles":30,"breadcrumbs":63,"productName":6,"productDescription":-1,"productVersionSlug":10,"localeId":-1,"landerSlug":7,"categorySlug":8,"_cmsSource":69,"hero":70,"quickLinks":75,"page_body":88,"meta_information":215,"sidebar_ad":219,"disclaimer":73,"stateSlug":72},"Healthcare Proxy","healthcare-proxy","healthcare","Document","hpro-3549","<center><p class='title center'><strong>Healthcare Proxy for Alabama<\u002Fstrong><\u002Fp><\u002Fcenter><br \u002F><br \u002F><p>WARNING TO PERSON SIGNING THIS DOCUMENT<\u002Fp><p>THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF ATTORNEY FOR HEALTHCARE. THE POWERS YOU GRANT BELOW CONTINUE TO BE EFFECTIVE SHOULD YOU BECOME DISABLED OR INCOMPETENT. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD READ THIS SECTION CAREFULLY AND ASK AN ATTORNEY TO EXPLAIN ANYTHING YOU DO NOT UNDERSTAND.<\u002Fp><p>Note: This form will be valid after you and your witnesses sign it. However, your healthcare Agent and any alternate must receive a copy of this document as well as sign and date a separate statement accepting his or her responsibilities before making any decisions on your behalf. The acceptance form is included at the end of this form.<\u002Fp><p class="center"><strong>SECTION 1.<br>    APPOINTMENT OF HEALTHCARE AGENT<\u002Fstrong><\u002Fp><p>I, <span style='background: #BBBBBB;'>_____________<\u002Fspan>, the <strong>"Principal,"<\u002Fstrong> appoint the following person as my healthcare <strong>"Agent"<\u002Fstrong> (which includes within its meaning a healthcare 'proxy,' 'surrogate,' 'representative,' 'executor,' or 'patient advocate' in jurisdictions that so require) to make healthcare decisions on my behalf and to have the authority specified herein. I have notified the Agent of my wishes concerning health care. I appoint the following individual as my healthcare Agent: <\u002Fp><p>Agent: <span style='background: #BBBBBB;'>_____________<\u002Fspan><\u002Fp><p>Relationship: <span style='background: #BBBBBB;'>_____________<\u002Fspan><\u002Fp><p>Address: <span style='background: #BBBBBB;'>_____________<\u002Fspan>  <br \u002F>  <span style='background: #BBBBBB;'>_____________<\u002Fspan>, <span style='background: #BBBBBB;'>_____________<\u002Fspan> <span style='background: #BBBBBB;'>_____________<\u002Fspan><\u002Fp><p>Phone Number: <span style='background: #BBBBBB;'>_____________<\u002Fspan><\u002Fp><p><strong>Agent's Authority.<\u002Fstrong> 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<\u002Fp><ol class="lower-alpha">  <li>authorize my admission to or discharge from any hospital, nursing care facility, or similar facility or service even against medical advice; <\u002Fli>  <li>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;<\u002Fli>  <li>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<\u002Fli>  <li>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.<\u002Fli><\u002Fol><p>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. <\u002Fp><p>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. <\u002Fp><p>(INITIAL IF APPLICABLE)<\u002Fp><p>____ 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 life-sustaining or death-delaying treatment to be provided or continued if my Agent believes the burdens of the treatment outweigh the expected benefits.<\u002Fp><p>_____ 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. <\u002Fp><p><strong><u>Medical Release and HIPAA Waiver of Confidentiality for My Agent (Optional)<\u002Fu><\u002Fstrong><\u002Fp><p>(INITIAL IF APPLICABLE)<\u002Fp><p>____ 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\u002FAIDs, 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 160-164. <\u002Fp><p class="center"><strong>SECTION 2.<br>    AUTOPSY<\u002Fstrong><\u002Fp><p>(NOTE: UNDER STATE LAW AN AUTOPSY MAY BE REQUIRED IN CERTAIN CIRCUMSTANCES REGARDLESS OF YOUR CONSENT) <\u002Fp><p>Filling out this section is optional. If you so choose to fill out this section, initial only one of the following: (INITIAL ONE)<\u002Fp><p>_____ I do not consent to an autopsy in any situation unless otherwise required by law. <\u002Fp><p>_____ I consent to an autopsy. <\u002Fp><p>_____ I authorize my Agent to decide whether I am to be autopsied. <\u002Fp><p class="center"><strong>SECTION 3.<br>    PHYSICIAN AFFIDAVIT (OPTIONAL)<\u002Fstrong><\u002Fp><p>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. <\u002Fp><p>I, Dr._____________________________, have reviewed this document with <span style='background: #BBBBBB;'>_____________<\u002Fspan> and have discussed his or her questions regarding the possible medical consequences of the medical choices provided herein. This discussion occurred on ______________ (date). <\u002Fp><p>I agreed to comply with the provisions of this directive. <\u002Fp><p>Physician's Signature: ____________________________________ <\u002Fp><p>Physician's Address: ____________________________________ <\u002Fp><p>                                    ________________________________________<\u002Fp><p>Date: _______________________ <\u002Fp><p class="center"><strong>SECTION 4.<br>    GENERAL PROVISIONS<\u002Fstrong><\u002Fp><p><strong>Effective Date.<\u002Fstrong> Unless otherwise stated below, my Agent's authority to make healthcare decisions shall take effect immediately.<\u002Fp><p>(INITIAL IF APPLICABLE)<\u002Fp><p>____ 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. <\u002Fp><p><strong>Duration and Revocation.<\u002Fstrong> 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 medical power of attorney.<\u002Fp><p><strong>Amendment.<\u002Fstrong> 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.<\u002Fp><p><strong>Jurisdiction, Severability, and Durability.<\u002Fstrong> 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.<\u002Fp><p><strong>Reliance of Third Parties on Healthcare Agent.<\u002Fstrong> 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. <\u002Fp><p>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. <\u002Fp><p><strong>Ratification.<\u002Fstrong> 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.<\u002Fp><p><strong>Signature of Agent.<\u002Fstrong> My Agent must use the following form when signing on my behalf pursuant to this Power of Attorney: [Principal Name] by [Agent Name], Agent.<\u002Fp><p><strong>Governing Law.<\u002Fstrong> This instrument is executed under and shall be construed according to the laws of Alabama.<\u002Fp><p><strong>Reliance on this Power of Attorney.<\u002Fstrong> 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.<\u002Fp><p><strong>Original Copy.<\u002Fstrong> The fully executed original copy of this Power of Attorney is in the possession of my Agent. <\u002Fp><p><strong>Acknowledgments.<\u002Fstrong> I have been provided with a disclosure statement explaining the effect of this document. I have read and understand the information contained in the disclosure statement.<\u002Fp><p class="center"><strong>SECTION 5.<br>    SIGNATURES OF HEALTHCARE AGENTS<\u002Fstrong><\u002Fp><ol>  <li>This Agent designation is not effective unless the patient is unable to participate in decisions regarding the patient's medical or mental health, as applicable. If this Agent designation includes the authority to make an anatomical gift, the authority remains exercisable after the patient's death.<\u002Fli>  <li>The Agent shall not exercise powers concerning the patient's care, custody, and medical or mental health treatment that the patient, if the patient were able to participate in the decision, could not have exercised on his or her own behalf.<\u002Fli>  <li>This Agent designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a patient who is pregnant if that would result in the pregnant patient's death.<\u002Fli>  <li>The Agent may make a decision to withhold or withdraw treatment that would allow a patient to die only if the patient has expressed in a clear and convincing manner that the Agent is authorized to make such a decision, and that the patient acknowledges that such a decision could or would allow the patient's death.<\u002Fli>  <li>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.<\u002Fli>  <li>The Agent shall act in accordance with the standards of care applicable to fiduciaries when acting for the patient and shall act consistent with the patient's best interests. The known desires of the patient expressed or evidenced while the patient is able to participate in medical or mental health treatment decisions are presumed to be in the patient's best interests.<\u002Fli>  <li>A patient may revoke his or her Agent designation at any time and in any manner sufficient to communicate intent to revoke.<\u002Fli>  <li>A patient 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 patient communicates his or her intent to revoke.<\u002Fli>  <li>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.<\u002Fli>  <\u002Fol>  <p><strong>Agent.<\u002Fstrong> I, <span style='background: #BBBBBB;'>_____________<\u002Fspan>, understand the above terms, conditions, and responsibilities and am willing to serve as the healthcare Agent for the named Principal. <\u002Fp><p>Signature: ________________________________________ <\u002Fp><p>Date: _________________________ <\u002Fp><p class="center"><strong>SECTION 6.<br>    MY SIGNATURE<\u002Fstrong><\u002Fp><p>I sign this Medical 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\u002For the appropriate number of witnesses as required by state law.<\u002Fp><p>Your Name: <span style='background: #BBBBBB;'>_____________<\u002Fspan><\u002Fp><p>Address: <span style='background: #BBBBBB;'>_____________<\u002Fspan>  <br \u002F>  <span style='background: #BBBBBB;'>_____________<\u002Fspan>, <span style='background: #BBBBBB;'>_____________<\u002Fspan> <span style='background: #BBBBBB;'>_____________<\u002Fspan><\u002Fp><p>Phone Number(s): <span style='background: #BBBBBB;'>_____________<\u002Fspan><\u002Fp><p>Date of Birth: <span style='background: #BBBBBB;'>_____________<\u002Fspan><\u002Fp><p>SSN or TIN: __________________________<\u002Fp><p>Your Signature: ____________________________________________________ <\u002Fp><p>Date Signed: __________________________ <\u002Fp><p class="center"><strong>SECTION 7.<br>    WITNESSES<\u002Fstrong><\u002Fp><p>(Note your state's witnessing requirements in the user instructions that come with this document.)<\u002Fp>  <p>I AM WITNESSING THIS FORM UNDER PENALTY OF PERJURY AND SWEAR AS FOLLOWS: that the individual who signed or acknowledged this Medical Power of Attorney is personally known to me, or that the individual's identity was proven to me by convincing evidence; that the individual signed or acknowledged this document in my presence; that I believe this person to be of sound mind and under no duress, fraud, or undue influence; that I did not sign the person's signature without consent; that I am not the healthcare Agent appointed in this document; that I am not the individual's attending physician, healthcare provider, an employee of the individual's healthcare provider, the operator of a community healthcare facility, the operator of a residential care facility for the elderly, a relative of an owner or operator of a healthcare facility in which the Principal is a patient or resident, nor an employee of an operator of a residential care facility for the elderly; that I am not related to the person by blood, adoption, or marriage and not entitled to any part of his or her estate under a currently existing will or by operation of law; and that I am at least 18 years of age and am not directly responsible for paying for his or her medical care.<\u002Fp>  <p>Name of first witness: ___________________________________<\u002Fp>  <p>Signature: _____________________________________________ <\u002Fp>  <p>Address of witness: _____________________________________<\u002Fp>  <p>                                 _____________________________________<\u002Fp>  <p>Date: _______________________ <\u002Fp>  <p>Name of second witness: _________________________________<\u002Fp>  <p>Signature: _____________________________________________ <\u002Fp>  <p>Address of witness: _____________________________________<\u002Fp>  <p>                                _____________________________________<\u002Fp>  <p>Date: _________________________ <\u002Fp>  <p><strong>Note: If the Principal is physically unable to sign,<\u002Fstrong> each witness must also sign the following statement: <\u002Fp><p>The Principal has directly indicated to me that this Medical Power of Attorney expresses his or her wishes and that the Principal intends to adopt this document at this time. <\u002Fp><p>Witness: ______________________________ Date: _____________<\u002Fp><p>Witness: ______________________________ Date: _____________<\u002Fp><div class='-page-break'><\u002Fdiv><center><p class='title center'><strong>Instructions for Your Healthcare Proxy<\u002Fstrong><\u002Fp><\u002Fcenter><br \u002F><br \u002F><p>Use the LegalNature healthcare proxy to designate someone you trust to make important healthcare decisions on your behalf. It is important to have a healthcare proxy 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.<\u002Fp><p>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 medical power of attorney in it, to specify your wishes concerning treatment you receive when you become too sick to speak for yourself.<\u002Fp><p>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 state-specific 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.<\u002Fp><p>In addition, the LegalNature medical 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.<\u002Fp><p><strong>Executing Your Healthcare Proxy<\u002Fstrong><\u002Fp><p>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.<\u002Fp><p><strong>Witnessing Requirements<\u002Fstrong><\u002Fp><p>In      Alabama, at least two witnesses must sign.    It is best (and we recommend) to have two disinterested witnesses AND a notary sign your power of attorney. 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",[76,80,84],{"id":77,"name":78,"link":79},"6a15a210f13133005943e6df","How To","#illustrated_steps",{"id":81,"name":82,"link":83},"6a15a210f13133005943e6e0","Help Guide","#help_guide",{"id":85,"name":86,"link":87},"6a15a210f13133005943e6e1","FAQS","#faqs",[89,108,125,131,156,162,168,195,198],{"id":90,"headline":91,"blockName":72,"items":92,"blockType":105,"visibility":106},"6a15a210f13133005943e6e6","When to use a healthcare proxy",[93,96,99,102],{"id":94,"text":95},"6a15a210f13133005943e6e2","To make sure a specific choice of healthcare is respected",{"id":97,"text":98},"6a15a210f13133005943e6e3","You want to give someone access to your medical records",{"id":100,"text":101},"6a15a210f13133005943e6e4","You want someone to speak to your doctors on your behalf",{"id":103,"text":104},"6a15a210f13133005943e6e5","You want to name a person you trust to make critical healthcare decisions","checkmarks",{"hideOnMobile":107,"hideOnDesktop":107},false,{"id":109,"headline":110,"description":111,"extraButton":72,"extraButtonUrl":72,"blockName":72,"columns":112,"blockType":123,"visibility":124},"6a15a210f13133005943e6e9","Rest easy knowing you will be cared for","Our healthcare proxy form allows you to name someone who has your best interests at heart as your agent.",[113,118],{"id":114,"title":115,"legacyHtml":116,"illustrationHtml":117,"buttonText":72,"buttonLink":72,"hideButton":107},"6a15a210f13133005943e6e7","Express Your Wishes","Our healthcare proxy provides you with the opportunity to clearly state your wishes in case you can no longer communicate due to illness or disability. 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Both the principal and the proxy will need to provide their name, phone number, and address. Our healthcare proxy form also allows you to name an alternate agent that will take the first agent's place in case he or she is unable to fulfill the required duties. \u003C\u002Fp>","\u003Cp>Complete Obligations\u003C\u002Fp>\u003Csvg width=\"275\" height=\"154\" viewBox=\"0 0 275 154\" fill=\"none\" xmlns=\"http:\u002F\u002Fwww.w3.org\u002F2000\u002Fsvg\">\r\n\u003Cpath d=\"M0 82.6465C0 107.804 13.8581 130.588 43.5 141.647C67.0231 150.423 82.8292 154.533 125.103 153.485C220.646 151.117 275 132.063 275 86.9409C275 41.8189 190.497 71.0744 110.241 18.5018C29.984 -34.0708 0 37.5245 0 82.6465Z\" fill=\"#D2E8FB\"\u002F>\r\n\u003Crect x=\"10\" y=\"28\" width=\"107\" height=\"38\" rx=\"5\" fill=\"white\"\u002F>\r\n\u003Ccircle cx=\"12\" cy=\"47\" r=\"11\" fill=\"#2DCB5F\"\u002F>\r\n\u003Cpath d=\"M10.8361 47.4074L15.9362 43.3403C16.4239 42.8774 17.3408 42.8959 17.8488 43.3403C18.3568 43.7848 18.3365 44.6204 17.8488 45.0833L12.1133 50.7856C11.4242 51.4707 10.2977 51.4246 9.66686 50.6854L6.37341 46.8264C5.88574 46.3634 5.86542 45.5278 6.37341 45.0833C6.8814 44.6389 7.79831 44.6204 8.28598 45.0833L10.8361 47.4074Z\" fill=\"white\"\u002F>\r\n\u003Cline x1=\"34.5\" y1=\"51.5\" x2=\"101.5\" y2=\"51.5\" stroke=\"#E9F0FA\" stroke-width=\"3\" stroke-linecap=\"round\"\u002F>\r\n\u003Cline x1=\"34.5\" y1=\"41.5\" x2=\"66.5\" y2=\"41.5\" stroke=\"#E9F0FA\" stroke-width=\"3\" stroke-linecap=\"round\"\u002F>\r\n\u003Crect x=\"147\" y=\"28\" width=\"107\" height=\"38\" rx=\"5\" fill=\"white\"\u002F>\r\n\u003Ccircle cx=\"149\" cy=\"47\" r=\"11\" fill=\"#2DCB5F\"\u002F>\r\n\u003Cpath d=\"M147.836 47.4074L152.936 43.3403C153.424 42.8774 154.341 42.8959 154.849 43.3403C155.357 43.7848 155.336 44.6204 154.849 45.0833L149.113 50.7856C148.424 51.4707 147.298 51.4246 146.667 50.6854L143.373 46.8264C142.886 46.3634 142.865 45.5278 143.373 45.0833C143.881 44.6389 144.798 44.6204 145.286 45.0833L147.836 47.4074Z\" fill=\"white\"\u002F>\r\n\u003Cline x1=\"171.5\" y1=\"51.5\" x2=\"238.5\" y2=\"51.5\" stroke=\"#E9F0FA\" stroke-width=\"3\" stroke-linecap=\"round\"\u002F>\r\n\u003Cline x1=\"171.5\" y1=\"41.5\" x2=\"203.5\" y2=\"41.5\" stroke=\"#E9F0FA\" stroke-width=\"3\" stroke-linecap=\"round\"\u002F>\r\n\u003Crect x=\"147\" y=\"91\" width=\"107\" height=\"38\" rx=\"5\" fill=\"white\"\u002F>\r\n\u003Ccircle cx=\"149\" cy=\"110\" r=\"11\" fill=\"#009EFF\"\u002F>\r\n\u003Cg clip-path=\"url(#clip0)\">\r\n\u003Cpath d=\"M145.694 105.793H152.03C152.28 105.793 152.483 105.991 152.483 106.234V106.529C152.483 106.772 152.28 106.97 152.03 106.97C152.03 108.642 151.068 110.054 149.751 110.5C151.068 110.946 152.03 112.358 152.03 114.03C152.28 114.03 152.483 114.228 152.483 114.471V114.766C152.483 115.009 152.28 115.207 152.03 115.207H145.694C145.444 115.207 145.241 115.009 145.241 114.766V114.471C145.241 114.228 145.444 114.03 145.694 114.03C145.694 112.358 146.656 110.946 147.973 110.5C146.656 110.054 145.694 108.642 145.694 106.97C145.444 106.97 145.241 106.772 145.241 106.529V106.234C145.241 105.991 145.444 105.793 145.694 105.793ZM146.901 114.03H150.823C150.823 112.606 149.952 111.383 148.862 111.383C147.772 111.383 146.901 112.606 146.901 114.03Z\" fill=\"white\"\u002F>\r\n\u003C\u002Fg>\r\n\u003Cline x1=\"171.5\" y1=\"114.5\" x2=\"238.5\" y2=\"114.5\" stroke=\"#E9F0FA\" stroke-width=\"3\" stroke-linecap=\"round\"\u002F>\r\n\u003Cline x1=\"171.5\" y1=\"104.5\" x2=\"203.5\" y2=\"104.5\" stroke=\"#E9F0FA\" stroke-width=\"3\" stroke-linecap=\"round\"\u002F>\r\n\u003Crect x=\"10\" y=\"91\" width=\"107\" height=\"38\" rx=\"5\" fill=\"white\"\u002F>\r\n\u003Ccircle cx=\"12\" cy=\"110\" r=\"11\" fill=\"#2DCB5F\"\u002F>\r\n\u003Cpath d=\"M10.8361 110.407L15.9362 106.34C16.4239 105.877 17.3408 105.896 17.8488 106.34C18.3568 106.785 18.3365 107.62 17.8488 108.083L12.1133 113.786C11.4242 114.471 10.2977 114.425 9.66686 113.685L6.37341 109.826C5.88574 109.363 5.86542 108.528 6.37341 108.083C6.8814 107.639 7.79831 107.62 8.28598 108.083L10.8361 110.407Z\" fill=\"white\"\u002F>\r\n\u003Cline x1=\"34.5\" y1=\"114.5\" x2=\"101.5\" y2=\"114.5\" stroke=\"#E9F0FA\" stroke-width=\"3\" stroke-linecap=\"round\"\u002F>\r\n\u003Cline x1=\"34.5\" y1=\"104.5\" x2=\"66.5\" y2=\"104.5\" stroke=\"#E9F0FA\" stroke-width=\"3\" stroke-linecap=\"round\"\u002F>\r\n\u003Cdefs>\r\n\u003CclipPath id=\"clip0\">\r\n\u003Crect width=\"7.24138\" height=\"9.41379\" fill=\"white\" transform=\"matrix(-1 0 0 1 152.483 105.793)\"\u002F>\r\n\u003C\u002FclipPath>\r\n\u003C\u002Fdefs>\r\n\u003C\u002Fsvg>\r\n",{"id":146,"headline":147,"legacyHtml":148,"illustrationHtml":122},"6a15a210f13133005943e6ed","Enter and Define the Terms","\u003Cp>Our healthcare proxy form will allow you to set and define any specific limitations on the proxy's powers. For example, you may limit the proxy's authority to admit the principal to certain facilities, such as a nursing home or a mental health clinic. Also, our form provides you with the flexibility to set a termination date for the agent's powers. \u003C\u002Fp>",{"id":150,"headline":151,"legacyHtml":152,"illustrationHtml":153},"6a15a210f13133005943e6ee","Review and Sign","\u003Cp>Next, review your document and make any final edits or clarifications. Follow your state's witnessing requirements when signing. These are included with the instructions that will be attached to your completed document. 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It is important to have a healthcare proxy 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.","\u003Ch4>\u003Cstrong>Proxy and Other Appointments\u003C\u002Fstrong>\u003C\u002Fh4>\n\u003Cp>In your state, this person may be called your proxy, agent, surrogate, representative, or something similar. Your proxy 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 \u003Ca href=\"https:\u002F\u002Fwww.legalnature.com\u002Fcategories\u002Fhealthcare\u002Fliving-will\" target=\"_blank\" rel=\"noopener\">living will\u003C\u002Fa> form, which includes a healthcare power of attorney in it, to specify your wishes concerning treatment you receive if you become too sick to speak for yourself.\u003C\u002Fp>\n\u003Cp>Your healthcare proxy needs to be at least 18 years old and mentally competent to follow your directions. In addition, read your document for any additional state-specific requirements. Many states prevent you from appointing your physician or an employee of your healthcare provider as your proxy. 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.\u003C\u002Fp>\n\u003Ch4>\u003Cstrong>Guardian\u003C\u002Fstrong>\u003C\u002Fh4>\n\u003Cp>In addition, LegalNature's healthcare proxy 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.\u003C\u002Fp>\n\u003Ch4>\u003Cstrong>Executing Your Healthcare Proxy\u003C\u002Fstrong>\u003C\u002Fh4>\n\u003Cp>It is very important that you read the ENTIRE document before signing. Not only are you delegating important authority to your proxy 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.\u003C\u002Fp>\n\u003Ch4>\u003Cstrong>Witnessing Requirements by State\u003C\u002Fstrong>\u003C\u002Fh4>\n\u003Cp>Some states only require the signatures of two witnesses \u003Cem>OR\u003C\u002Fem> a notary. However, it is best \u003Cem>(and we highly recommend)\u003C\u002Fem> to have two disinterested witnesses \u003Cem>AND\u003C\u002Fem> a notary sign your healthcare proxy.\u003C\u002Fp>","help-guide",{"hideOnMobile":107,"hideOnDesktop":107},{"id":163,"style":164,"size":165,"blockName":72,"blockType":166,"visibility":167},"6a15a210f13133005943e6f1","line","md","separator",{"hideOnMobile":107,"hideOnDesktop":107},{"id":169,"heading":170,"background":171,"blockName":72,"items":172,"blockType":193,"visibility":194},"6a15a210f13133005943e6f7","Frequently Asked Questions","white",[173,177,181,185,189],{"id":174,"question":175,"answer":72,"legacyHtml":176},"6a15a210f13133005943e6f2","What is a healthcare proxy?","\u003Cp>\u003Cspan>A \u003C\u002Fspan>healthcare proxy\u003Cspan> is the legal document that often becomes effective when a person (i.e., the principal) becomes incapacitated due to illness or injury. The main objective of a healthcare proxy is to meet any medical needs that may arise if the principal is incapable of taking care of him or herself. \u003C\u002Fspan>\u003C\u002Fp>",{"id":178,"question":179,"answer":72,"legacyHtml":180},"6a15a210f13133005943e6f3","Who needs a healthcare proxy?","\u003Cp>Some people with pre-existing conditions or a degenerative disease often have a real need for a healthcare proxy in order to name their agent. In any case, a healthcare proxy is a straightforward way to document a person’s wishes in the event that they can no longer express them.\u003C\u002Fp>",{"id":182,"question":183,"answer":72,"legacyHtml":184},"6a15a210f13133005943e6f4","What should I include in my healthcare proxy?","\u003Cp>The purpose of a healthcare proxy is to give the principal the opportunity to clearly express their healthcare wishes as well as name their agent. Examples include any of the following:\u003Cbr \u002F>\u003Cbr \u002F>\u003C\u002Fp>\n\u003Cul>\n\u003Cli>Preferences regarding health and wellness\u003C\u002Fli>\n\u003Cli>The principal's choice of healthcare providers\u003C\u002Fli>\n\u003Cli>Instructions regarding end-of-life care\u003C\u002Fli>\n\u003Cli>The rejection of certain medical treatments\u003C\u002Fli>\n\u003C\u002Ful>",{"id":186,"question":187,"answer":72,"legacyHtml":188},"6a15a210f13133005943e6f5","What's the difference between a healthcare proxy and a power of attorney? ","\u003Cp>Although they have much in common, unlike a healthcare proxy, a power of attorney allows for the management of financial affairs, the purchase of life insurance, the operations of business interests, among other non-healthcare-related decisions and transactions. Use \u003Ca href=\"https:\u002F\u002Fwww.legalnature.com\u002Fcategories\u002Fpersonal-affairs\u002Fpower-of-attorney\" rel=\"follow noopener\" target=\"_blank\">LegalNature's power of attorney form\u003C\u002Fa> to easily to draft a thorough and legally sound power of attorney. \u003C\u002Fp>",{"id":190,"question":191,"answer":72,"legacyHtml":192},"6a15a210f13133005943e6f6","Who can be named as agent in the healthcare proxy?","\u003Cp>In choosing who will be your proxy, one of the most important elements to consider is trust. After all, the person you name will be legally authorized to represent you and speak on your behalf regarding any health-related matter. Also, it is important that the person you name has views similar to your own on matters such as religion, blood transfusions, resuscitation procedures, and life-support. That said, our healthcare proxy allows the principal to limit the proxy's powers by explicitly rejecting any unwanted medical procedures. \u003C\u002Fp>","faqs",{"hideOnMobile":107,"hideOnDesktop":107},{"id":196,"style":164,"size":165,"blockName":72,"blockType":166,"visibility":197},"6a15a210f13133005943e6f8",{"hideOnMobile":107,"hideOnDesktop":107},{"id":199,"headline":200,"text":201,"image":202,"ctaText":72,"blockName":72,"blockType":213,"visibility":214},"6a15a210f13133005943e6f9","Start Your Healthcare Proxy","Complete your healthcare proxy in minutes with LegalNature's intuitive, step-by-step guidance.",{"id":203,"alt":72,"updatedAt":204,"createdAt":205,"url":206,"thumbnailURL":72,"filename":207,"mimeType":208,"filesize":209,"width":210,"height":211,"focalX":212,"focalY":212},210,"2026-07-24T10:46:14.235Z","2026-07-24T10:46:14.133Z","https:\u002F\u002Fs3.us-east-2.amazonaws.com\u002Fshared-cms-main-media.legalnature.com\u002Fgeneral-doc-image.jpg","general-doc-image.jpg","image\u002Fjpeg",369412,894,594,50,"get-started",{"hideOnMobile":107,"hideOnDesktop":107},{"title":216,"description":217,"keyword":6,"og_image":218},"Healthcare Proxy | Create & Print | LegalNature","Appoint a trusted person to make medical decisions on your behalf. Create a healthcare proxy with LegalNature in any state.","https:\u002F\u002Fs3.us-east-2.amazonaws.com\u002Fshared-cms-main-media.legalnature.com\u002FUI1GNAcPRmcnaSYDkLET.jpg",{"headline":72,"image":72,"imageUrl":72,"steps":220},[]]