Rhode Island Statutory Form Durable Power of Attorney for Health Care

RHODE ISLAND STATUTORY FORM

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

R.I. Gen. Laws § 23-4.10-2

WARNING TO PERSON EXECUTING THIS DOCUMENT

This is an important legal document which is authorized by the general laws of this state. Before executing this document, you should know these important facts:

You must be at least eighteen (18) years of age and a resident of the state for this document to be legally valid and binding.

This document gives the person you designate as your agent (the attorney in fact) the power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known.

Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.

Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection at the time, and health care necessary to keep you alive may not be stopped or withheld if you object at the time.

This document gives your agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. This power is subject to any statement of your desires and any limitation that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your agent to make health care decisions for you if your agent: (1) authorizes anything that is illegal; (2) acts contrary to your known desires; or (3) where your desires are not known, does anything that is clearly contrary to your best interests.

Unless you specify a specific period, this power will exist until you revoke it. Your agent’s power and authority ceases upon your death except to inform your family or next of kin of your desire, if any, to be an organ and tissue owner.

You have the right to revoke the authority of your agent by notifying your agent or your treating doctor, hospital, or other health care provider orally or in writing of the revocation.

Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.

This document revokes any prior durable power of attorney for health care.

You should carefully read and follow the witnessing procedure described at the end of this form. This document will not be valid unless you comply with the witnessing procedure.

If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.

Your agent may need this document immediately in case of an emergency that requires a decision concerning your health care. Either keep this document where it is immediately available to your agent and alternate agents or give each of them an executed copy of this document. You may also want to give your doctor an executed copy of this document.

(1) DESIGNATION OF HEALTH CARE AGENT

I, __________________________________________________________

_________________________________________________________________

_________________________________________________________________

(insert your name and address)

do hereby designate and appoint: ______________________________________

_________________________________________________________________

(Insert the name, address, and telephone number of one individual only as your agent. None of the following may be designated: your treating health care provider; a nonrelative employee of that provider; an operator of a community care facility; or a nonrelative employee of such an operator.)

as my attorney in fact (agent) to make health care decisions for me as authorized in this document. For purposes of this document, “health care decision” means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual’s physical or mental condition.

(2) CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE

By this document I intend to create a durable power of attorney for health care.

(3) GENERAL STATEMENT OF AUTHORITY GRANTED

Subject to any limitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures and informing my family or next of kin of my desire, if any, to be an organ or tissue donor.

(You may limit your agent’s authority or state your desires in paragraph (4).)

(4) STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS

Your agent must make health care decisions consistent with your known desires. You may state desires concerning life-prolonging care and other health care, identify treatment you do not want, and limit your agent’s authority. If you state no limits, your agent will have broad powers except as limited by law.

(a) Statement of desires concerning life-prolonging care, treatment, services, and procedures:

_________________________________________________________________

_________________________________________________________________

(b) Additional statement of desires, special provisions, and limitations regarding health care decisions:

_________________________________________________________________

_________________________________________________________________

(c) Statement of desire regarding organ and tissue donation:

Initial if applicable:

□ In the event of my death, I request that my agent inform my family/next of kin of my desire to be an organ and tissue donor, if possible.

(You may attach additional pages. Date and sign EACH additional page at the same time you date and sign this document.)

(5) INSPECTION AND DISCLOSURE OF HEALTH INFORMATION

Subject to any limitations in this document, my agent may: (a) request, review, and receive verbal or written information regarding my physical or mental health, including medical and hospital records; (b) execute releases or other documents required to obtain it; and (c) consent to its disclosure.

(State any limits on this authority in paragraph (4).)

(6) SIGNING DOCUMENTS, WAIVERS, AND RELEASES

Where necessary to implement an authorized health care decision, my agent may execute on my behalf: (a) documents titled or purporting to be a “Refusal to Permit Treatment” and “Leaving Hospital Against Medical Advice”; and (b) any necessary waiver or release from liability required by a hospital or physician.

(7) DURATION

Unless you specify a shorter period below, this power of attorney will exist until revoked.

This durable power of attorney for health care expires on: ______________________

(Complete only if you want the agent’s authority to end on a specific date.)

(8) DESIGNATION OF ALTERNATE AGENTS

You are not required to designate alternates. An alternate may act, in the order listed, if the agent is unavailable, ineligible, lacks capacity, or has had the appointment or authority revoked. A spouse-agent becomes ineligible if the marriage is dissolved.

(A) First Alternate Agent: ___________________________________________

_________________________________________________________________

(name, address, and telephone number)

(B) Second Alternate Agent: _________________________________________

_________________________________________________________________

(name, address, and telephone number)

(9) PRIOR DESIGNATIONS REVOKED

I revoke any prior durable power of attorney for health care.

DATE AND SIGNATURE OF PRINCIPAL

YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY.

I sign this Statutory Form Durable Power of Attorney for Health Care on ____________ at ________________________, ________.

Date City State

__________________________________________

Signature of Principal

THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED BY ONE NOTARY PUBLIC OR TWO (2) QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE.

STATEMENT OF WITNESSES / NOTARY

This document must be witnessed by two (2) qualified adult witnesses or one (1) notary public. A witness may not be: (1) an agent or alternate agent; (2) a health care provider; (3) an employee of a health care provider; (4) an operator of a community care facility; or (5) an employee of such an operator.

I declare under penalty of perjury that the person who signed or acknowledged this document is personally known to me to be the principal; the principal signed or acknowledged it in my presence; the principal appears to be of sound mind and under no duress, fraud, or undue influence; and I am not an appointed attorney in fact, health care provider, employee of a health care provider, operator of a community care facility, or employee of such an operator.

OPTION 1 — ONE NOTARY PUBLIC (complete this OR Option 2)

__________________________________________

Signature of Notary Public

Printed name: ___________________________________

Date: ____________________

My commission expires: ______________________

OPTION 2 — TWO QUALIFIED WITNESSES (complete this OR Option 1)

First Qualified Witness

__________________________________________

Signature

Printed name: ___________________________________

Residence address: __________________________________________

Date: ____________________

Second Qualified Witness

__________________________________________

Signature

Printed name: ___________________________________

Residence address: __________________________________________

Date: ____________________

AT LEAST ONE OF THE TWO WITNESSES, OR THE NOTARY PUBLIC, MUST ALSO SIGN THE FOLLOWING DECLARATION.

I further declare under penalty of perjury that I am not related to the principal by blood, marriage, or adoption and, to the best of my knowledge, I am not entitled to any part of the principal’s estate upon the principal’s death under an existing will or by operation of law.

__________________________________________

Signature of Declarant

Printed name: ___________________________________

COMPLETION CHECKLIST — NOT PART OF THE STATUTORY FORM

• Complete only one execution path: Option 1 (one notary public) OR Option 2 (two qualified adult witnesses).

• If using Option 2, confirm that neither witness is disqualified under the list above.

• Have at least one witness—or the notary—sign the additional relationship-and-inheritance declaration.

• Wet-initial the organ-and-tissue donor choice only if it applies. Date and sign every attached page when signing this form.

• Keep the signed original available and consider giving executed copies to your agent, alternate agents, and doctor.

Review the completed form for blank names, inconsistent choices, or unsigned attachments before distributing copies.