MAKE YOUR FREE North Carolina Medical Power of Attorney

HEALTHCARE POWER OF ATTORNEY

NOTE: YOU SHOULD USE THIS DOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE AGENT IF YOU ARE COMFORTABLE GIVING THAT PERSON BROAD AND SWEEPING POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A HEALTH CARE POWER OF ATTORNEY.

EXPLANATION: You have the right to name someone to make health care decisions for you when you cannot make or communicate those decisions. If you prepare your own health care power of attorney, you should be very careful to make sure it is consistent with North Carolina law. This document gives the person you designate as your health care agent broad powers to make health care decisions for you when you cannot make the decision yourself or cannot communicate your decision to other people. You should discuss your wishes concerning life-prolonging measures, mental health treatment, and other health care decisions with your health care agent. Except to the extent that you express specific limitations or restrictions in this form, your health care agent may make any health care decision you could make yourself.

This form does not impose a duty on your health care agent to exercise granted powers, but when a power is exercised, your health care agent will be obligated to use due care to act in your best interests and in accordance with this document.

This Health Care Power of Attorney form is intended to be valid in any jurisdiction in which it is presented, but places outside North Carolina may impose requirements that this form does not meet. If you want to use this form, you must complete it, sign it, and have your signature witnessed by two qualified witnesses and proved by a notary public. Follow the instructions about which choices you can initial very carefully. Do not sign this form until two witnesses and a notary public are present to watch you sign it. You then should give a copy to your health care agent and to any alternates you name. You should consider filing it with the Advance Health Care Directive Registry maintained by the North Carolina Secretary of State: http://www.nclifelinks.org/ahcdr/

. DESIGNATION OF HEALTH CARE AGENT. I, , of , , being of sound mind, hereby appoint the following person(s):

to serve as my health care agent(s) 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.

(NOTICE: Any competent person who is not engaged in providing health care to the Principal for remuneration, and who is 18 years of age or older, may act as a Health Care Agent.)

. EFFECTIVENESS OF APPOINTMENT. (NOTICE: This Health Care Power of Attorney may be revoked by you at any time in any manner by which you are able to communicate your intent to revoke to your Health Care Agent and your attending physician.)

My designation of a health care agent expires only when I revoke it. Absent, 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.

. 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.

. GENERAL STATEMENT OF AUTHORITY GRANTED. Except as indicated below, I hereby grant to my Health Care Agent named above full power and authority to make health care decisions on my behalf, including, but not limited to, the following:

. 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, hospice, long-term care facility or other health care provider.

. 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, podiatrist or other health care provider. This authorization specifically includes the power to consent to measures for relief of pain.

. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers.

. Providing my medical information at the request of any individual acting as my attorney-in-fact under a durable power of attorney or as a Trustee or successor Trustee under any Trust Agreement of which I am a Grantor or Trustee, or at the request of any other individual whom my health care agent believes should have such information. I desire that such information be provided whenever it would expedite the prompt and proper handling of my affairs or the affairs of any person or entity for which I have some responsibility. In addition, I authorize my health care agent to take any and all legal steps necessary to ensure compliance with my instructions providing access to my protected health information. Such steps shall include resorting to any and all legal procedures in and out of courts as may be necessary to enforce my rights under the law and shall include attempting to recover attorneys' fees against anyone who does not comply with this health care power of attorney.

. To the extent I have not already made valid and enforceable arrangements during my lifetime that have not been revoked, exercising any right I may have to authorize an autopsy or direct the disposition of my remains.

. Taking any lawful actions that may be necessary to carry out these decisions, including, but not limited to: (i) signing, executing, delivering, and acknowledging any agreement, release, authorization, or other document that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of these powers; (ii) granting releases of liability to medical providers or others; and (iii) incurring reasonable costs on my behalf related to exercising these powers, provided that this health care power of attorney shall not give my health care agent general authority over my property or financial affairs.

. SPECIAL LIMITATIONS ABOUT ARTIFICIAL NUTRITION OR HYDRATION. In exercising the authority to make health care decisions on my behalf, my health care agent

_________

(Initials) (NOTE: DO NOT initial unless you insert a limitation in the space above.)

. SPECIAL LIMITATIONS ON AGENT'S AUTHORITY TO MAKE HEALTH CARE DECISIONS. In exercising the authority to make health care decisions on my behalf, the authority of my health care agent is subject to the following special provisions: (Here you may include any specific provisions you deem appropriate such as: your own definition of when life-prolonging measures should be withheld or discontinued, or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs, or are unacceptable to you for any other reason.)

. ADVANCE INSTRUCTION FOR MENTAL HEALTH TREATMENT. (Notice: This health care power of attorney may incorporate or be combined with an advance instruction for mental health treatment, executed in accordance with Part 2 of Article 3 of Chapter 122C of the General Statutes, which you may use to state your instructions regarding mental health treatment in the event you lack capacity to make or communicate mental health treatment decisions. Because your health care agent's decisions must be consistent with any statements you have expressed in an advance instruction, you should indicate here whether you have executed an advance instruction for mental health treatment):

I HAVE executed a document containing advance instruction for mental health treatment.

_______

(Initials) (NOTE: DO NOT initial unless you insert a limitation in the space above.)

. AUTOPSY AND DISPOSITION OF REMAINS. In exercising the authority to make decisions regarding autopsy and disposition of remains on my behalf, the authority of my health care agent is subject to the following special provisions and limitations. (Here you may include any specific limitations you deem appropriate such as: limiting the grant of authority and the scope of authority, or instructions regarding burial or cremation):

I to authorize an autopsy, and direct the disposition of my remains.

_______

(Initials) (NOTE: DO NOT initial unless you insert a limitation in the space above.)

. ORGAN DONATION. To the extent I have not already made valid and enforceable arrangements during my lifetime that have not been revoked, my health care agent

________

(Initial)

NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN THIS INSTRUMENT WITHOUT YOUR INITIALS.

. RELIANCE OF THIRD PARTIES ON HEALTH CARE AGENT.

1. No person who relies in good faith upon the authority of or any representations by my Health Care Agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions by my Health Care Agent.

2. The powers conferred on my Health Care Agent by this document may be exercised by my Health Care Agent alone, and my Health Care Agent's signature or act 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 Health Care 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 Health Care Agent pursuant to this power of attorney shall be superior to and binding upon my family, relatives, friends, and others.

. MISCELLANEOUS PROVISIONS.

1. Revocation of Prior Powers of Attorney. I revoke any prior Health Care Power of Attorney. The preceding sentence is not intended to revoke any general powers of attorney, some of the provisions of which may relate to health care; however, this power of attorney shall take precedence over any health care provisions in any valid general power of attorney I have not revoked.

2. Jurisdiction, Severability, and Durability. This Health Care Power of Attorney is intended to be valid in any jurisdiction in which it is presented. The powers delegated under this power of attorney are severable, so that the invalidity of one or more powers shall not affect any others. This power of attorney shall not be affected or revoked by my incapacity or mental incompetence.

3. My Health Care Agent and my Health Care Agents's estate, heirs, successors, and assigns are hereby released and forever discharged by me, my estate, my heirs, successors, and assigns and personal representatives from all liability and from all claims or demands of all kinds arising out of the acts or omissions of my Health Care Agent pursuant to this document, except for willful misconduct or gross negligence.

4. Health Care Agent Not Liable. My Health Care Agent and my Health Care Agents's estate, heirs, successors, and assigns are hereby released and forever discharged by me, my estate, my heirs, successors, and assigns and personal representatives from all liability and from all claims or demands of all kinds arising out of the acts or omissions of my Health Care Agent pursuant to this document, except for willful misconduct or gross negligence.

5. No Civil or Criminal Liability. No act or omission of my Health Care Agent, or of any other person, institution, or facility acting in good faith in reliance on the authority of my Health Care Agent pursuant to this Health Care Power of Attorney shall be considered suicide, nor the cause of my death for any civil or criminal purposes, nor shall it be considered unprofessional conduct or as lack of professional competence. Any person, institution, or facility against whom criminal or civil liability is asserted because of conduct authorized by this Health Care Power of Attorney may interpose this document as a defense.

6. Reimbursement. My health care agent shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provision of this directive.

. SIGNATURE OF PRINCIPAL. By signing here, I indicate that I am mentally alert and competent, fully informed as to the contents of this document, and understand the full import of this grant of powers to my Health Care Agent.

Signed on _____ day of ____________________, _____.

. SIGNATURE OF WITNESSES (signed in the presence of a Notary Public). I hereby state that the Principal, , being of sound mind, signed (or directed another to sign on the principal's behalf) the foregoing Health Care Power of Attorney in my presence, and that I am not related to the Principal by blood or marriage, and I would not be entitled to any portion of the estate of the Principal under any existing will or codicil of the Principal or as an heir under the Intestate Succession Act, if the Principal died on this date without a will. I also state that I am not the Principal's attending physician, nor an employee of the Principal's attending physician, nor an employee of the health facility in which the Principal is a patient, nor an employee of a nursing home or any group care home where the Principal resides. I further state that I do not have any claim against the Principal.

Date: _________________________

Date: _________________________

State of North Carolina

County of _________________________

CERTIFICATE

I, ___________________________________, Notary Public for ________________________ County hereby certify that , the Principal, appeared before me and swore to me and to the witnesses in my presence that this instrument is a Health Care Power of Attorney, and that he/she had willingly and voluntarily made and executed it as his/her free act and deed for the purposes expressed in it.

I further certify that and , witnesses appeared before me and swore that they witnessed , Principal, sign the attached Health Care Power of Attorney, believing him/her to be of sound mind; and also swore that at the time they witnessed the signing (i) they were not related within the third degree to the Principal or to the Principal's spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the Principal upon the Principal's death under any will of the Principal or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the Principal or an employee of an attending physician or an employee of a health facility in which the Principal was a patient or an employee of a nursing home or any group-care home which the Principal resided, and (iv) they did not have a claim against the Principal. I further certify that I am satisfied as to the genuineness and due execution of the instrument.

Dated this _____ day of _______________, _____.

_________________________________________________________

NOTARY PUBLIC FOR THE COUNTY OF ____________________