Minnesota Durable Power of Attorney for Health Care Decisions

MINNESOTA DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS

GENERAL STATEMENT OF AUTHORITY GRANTED

When I am unable to decide or speak for myself, I, ________________________________________, the Principal, trust and appoint:

____________________________________________ [Agent’s full legal name]
____________________________________________ [Agent’s address] 
____________________________________________ [Agent’s city, state, and zip code] 
____________________________________________ [Agent’s telephone number]
____________________________________________ [Agent’s e-mail address]

to make health care decisions for me pursuant to the language stated below. This person is called my health care Agent. I authorize my Agent, on my behalf, to:

(1) consent, refuse consent, or withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition, and to make decisions about organ donation, autopsy and disposition of the body;

(2) make all necessary arrangements at any hospital, psychiatric hospital or psychiatric treatment facility, hospice, nursing home or similar institution; to employ or discharge health care personnel to include physicians, psychiatrists, psychologists, dentists, nurses, therapists or any other person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care as the Agent shall deem necessary for my physical, mental and emotional well being; and

(3) request, receive and review any information, verbal or written, regarding my personal affairs or physical or mental health including medical and hospital records and to execute any releases of other documents that may be required in order to obtain such information.

(Optional) If my health care agent is not reasonably available, I trust and appoint the following individual to be my health care Agent instead:

____________________________________________ [Alternate Agent’s full legal name]
____________________________________________ [Alternate Agent’s address]
____________________________________________ [Alternate Agent’s city, state, and zip code]
____________________________________________ [Alternate Agent’s telephone number]
____________________________________________ [Alternate Agent’s e-mail address]

In exercising the grant of authority set forth above my Agent for health care decisions shall:

______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
(Here may be inserted any special instructions or statement of the Principal's desires to be followed by the Agent in exercising the authority granted.)

LIMITATIONS OF AUTHORITY

(1) The powers of the Agent herein shall be limited to the extent set out in writing in this durable power of attorney for health care decisions, and shall not include the power to revoke or invalidate any previously existing declaration made in accordance with the natural death act.

(2) The Agent shall be prohibited from authorizing consent for the following items:

______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

(3) This durable power of attorney for health care decisions shall be subject to the additional following limitations:

______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________

REVOCATION

Any durable power of attorney for health care decisions I have previously made is hereby revoked. (This durable power of attorney for health care decisions shall be revoked by an instrument in writing executed, witnessed or acknowledged in the same manner as required herein or set out another manner of revocation, if desired.)

EXECUTION

Executed this ______ day of ____________________ (month, year), at ____________________ (city), Minnesota.

__________________________________________
Signature of Person Making Declaration (Principal)


__________________________________________
(Type or Print Name of Principal)


__________________________________________
Street Address

__________________________________________
City State Zip Code

WITNESSES

Two witnesses must sign. Only one of the two witnesses can be a health care provider or an employee of a health care provider giving direct care to the principal on the day the principal signs this document.

Witness One:

(i) In my presence on ________________ (date), ____________________________________________ (name) acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf.

(ii) I am at least 18 years of age.

(iii) I am not named as a health care agent or an alternate health care agent in this document.

(iv) If I am a health care provider or an employee of a health care provider giving direct care to the principal, I must initial this box: [______]

I certify that the information in (i) through (iv) is true and correct.

__________________________________________
Signature of Witness #1

__________________________________________
(Type or Print Name of Witness #1)

__________________________________________
Street Address

__________________________________________
City State Zip Code

Witness Two:

(i) In my presence on ________________ (date), ____________________________________________ (name) acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf.

(ii) I am at least 18 years of age.

(iii) I am not named as a health care agent or an alternate health care agent in this document.

(iv) If I am a health care provider or an employee of a health care provider giving direct care to the principal, I must initial this box: [______]

I certify that the information in (i) through (iv) is true and correct. 

__________________________________________
Signature of Witness #1

__________________________________________
(Type or Print Name of Witness #1)

__________________________________________
Street Address

__________________________________________
City State Zip Code

STATE OF MINNESOTA    )
                                            ) ss.
COUNTY OF ___________)

CERTIFICATE OF NOTARY PUBLIC

In my presence on ______________________ (date), ___________________________________________ (name) acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. I am not named as a health care agent or alternate health care agent in this document.

 
__________________________________
(Signature of Notary Public or other Official)

 Copies Delivered To:
__________________________________________ 
__________________________________________
__________________________________________
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