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Durable Power Of Attorney For Health Care (North Carolina) POA-NC 101 - Legal Forms
| Durable Power Of Attorney For Health Care (North Carolina) Form. This is a Legal Forms form and can be used in Health Care-Living Wills Power Of Attorney . |
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North Carolina Health Care Power of Attorney Pursuant to North Carolina General Statutes ยง 32A-15 Introduction You have the right to control the decisions about your medical care. To make these decisions, you must be competent and able to communicate. If you are not competent or able to communicate, someone else must make these decisions for you. A health care power of attorney allows you to choose this person. This publication explains what a health care power of attorney is and how it is used. STATE OF NORTH CAROLINA COUNTY OF HEALTH CARE POWER OF ATTORNEY (Notice: This document gives the person you designate your health care agent broad powers to make health care decisions, including mental health treatment decisions, for you. Except to the extent that you express specific limitations or restrictions on the authority of your health care agent, this power includes the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive, admit you to a facility, and administer certain treatments and medications. This power exists only as to those health care decisions for which you are unable to give informed consent. This form does not impose a duty on your health care agent to exercise granted powers, but when a power is granted, your health care agent will have to use due care to act in your best interests and in accordance with this document. For mental health treatment decisions, your health care agent will act according to how the health care agent believes you would act if you were making the decision. Because the powers granted by this document are broad and sweeping, you should discuss your wishes concerning life-sustaining procedures, mental health treatment, and other health care decisions with your health care agent. Use of this form in the creation of a health care power of attorney is lawful and is authorized pursuant to North Carolina law. However, use of this form is an optional and nonexclusive method for creating a health care power of attorney and North Carolina law does not bar the use of any other or different form of power of attorney for health care that meets the statutory requirements.) Designation of Agent. I, hereby appoint Name: Home Address: Home Telephone Number: Work Telephone Number: as my health care attorney-in-fact (herein referred to as my "health care agent") to act for me and in my name (in any way I could act in person) to make health care decisions for me as authorized in this document. If the person named as my health care agent is not reasonably available or is unable or unwilling to act as my agent, then I appoint the following persons (each to act alone and successively, in the order named), to serve in that capacity: (Optional) A. Name: Home Address: Home Telephone Number: Work Telephone Number: B. Name: Home Address: 1. , being of sound mind, Home Telephone Number: Work Telephone Number: Each successor health care agent designated shall be vested with the same power and duties as if originally named as my health care agent. 2. Effectiveness of Appointment. My designation of a health care agent expires only when I revoke it. Absent revocation, the authority granted in this document shall become effective when and if one of the physician(s) listed below determines that I lack capacity to make or communicate decisions relating to my health care, and will continue in effect during that incapacity, or until my death, except if I authorize my health care agent to exercise my rights with respect to anatomical gifts, autopsy, or disposition of my remains, this authority will continue after my death to the extent necessary to exercise that authority. 1. 2. (Physician) (Physician) If I have not designated a physician, or no physician(s) named above is reasonably available, the determination that I lack capacity to make or communicate decisions relating to my health care shall be made by my attending physician. 3. Revocation. 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 health care agent or my health care provider. 4. General Statement of authority granted. Except as indicated in section 4 below, I hereby grant to my health care agent named above full power and authority to make health care decisions, including mental health treatment decisions on my behalf, including, but not limited to, the following: A. To request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this information. To employ or discharge my health care providers. To consent to and authorize my admission to and discharge from a hospital, nursing or convalescent home, or other institution; To consent to and authorize my admission to and retention in a facility for the care or treatment of mental illness. To give consent to and authorize the administration of medications for mental health treatment and electroconvulsive treatment (ECT) commonly referred to as "shock treatment". To give consent for, to withdraw consent for, or to withhold consent for, X ray, anesthesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed physician, dentist, or podiatrist. This authorization specifically includes the power to consent to measures for relief of pain. To authorize the withholding or withdrawal of life-sustaining procedures when and if my physician determines that I am terminally ill, permanently in a coma, suffer severe dementia, or am in a persistent vegetative state. Lifesustaining procedures are those forms of medical care that only serve to artificially prolong the dying process and may include mechanical ventilation, dialysis, antibiotics, artificial nutrition and hydration, and other forms of medical treatment which sustain, restore or supplant vital bodily functions. Life-sustaining procedures do not include care necessary to provide comfort or alleviate pain. To exercise any right that I may have to make a disposition of any part of all of my body for medical purposes, to donate my organs, to authorize an autopsy, and to direct the disposition of my remains. B. C. D. E. F. G. H. I. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liabil
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