Advance Directive Of Appointment Of Agent
The Trust and Estate Department offers this document for consideration as a form for an advance directive under 18 VSA § 9701 et seq.
ADVANCE DIRECTIVE Of APPOINTMENT OF AGENT
I,———————____________________ , with a current mailing address of__________________, hereby appoint__________________, with a current address of ______________________, and a current telephone number of ________________ to serve as my health care agent and to exercise all of the following powers and discretions.
If __________________________ is unable, unwilling or unavailable to act as my health care agent, I hereby appoint _____________________ with a current address of _______________ and a current telephone number of _______________ as alternate agent.
Should a petition be filed to nominate a guardian for me, I wish the above individuals, and in the order set forth above, be nominated to act as my guardian. Should an individual be named below as a person I do not wish to act as a health care decision-maker, I do not wish them to serve as my guardian.
AGENT’S POWERS
I give my agent the following powers on the Effective Date indicated below and subject to its terms and conditions:
I. Health Care
a. To make any and all health care decisions for me, except to the extent I state otherwise in this document.
b. To make decisions regarding life sustaining treatment consistent with the general statement, set forth below, next to my initials.
Select ONE:
___ If I suffer a condition from which there is no reasonable prospect of regaining my ability to think and act for myself, I want only care directed to my comfort and dignity, and authorize my agent to decline all treatment (including artificial nutrition and hydration) the primary purpose of which is to prolong my life.
___ If I suffer a condition from which there is no reasonable prospect of regaining the ability to think and act for myself, I want care directed to my comfort and dignity, and also want artificial nutrition and hydration if needed, but authorize my agent to decline all other treatment the primary purpose of which is to prolong my life.
___ I want my life sustained by any reasonable medical measures, regardless of my condition.
___ I wish ____________________________________________________________
__________________________________________________________________
c. Hospice Care:
___ I want hospice care as close to home as possible. The possible locations for such care shall include but not be limited to my home, a hospice facility, or nursing home.
___ I do not want hospice care.
d. I do not desire the following types of health care (e.g., transfer from home, hospitalization, treatment not authorized during pregnancy, etc.):
_______________________________________________________________
_______________________________________________________________.
II. Anatomical Gifts
a. To make any and all decisions regarding giving any or all of my remains as an anatomical gift.
b. To make decisions regarding anatomical gifts consistent with the general statement, set forth below, next to my initials .
___ My agent has the discretion to make an anatomical gift of any of my organs or tissues.
___ Only the following organs or tissues ____________________________________
_________________________________________________________________.
___ I decline to make an anatomical gift.
c. Designated Donee of Anatomical Gift :
III. Disposition of Remains
a. To make any and all decisions regarding the disposition of my remains or funeral goods and services, except to the extent I state otherwise in this document.
b. To make decisions regarding arrangements for the disposition of my remains and funeral services consistent with the general statement, set forth below, next to my initials
___ I have entered into an irrevocable pre-need contract with a funeral director, crematory, or cemetery, my agent’s decisions shall be consistent with the pre-need contract.
___ I direct my agent to _____________________________________________
_________________________________________________________________.
___ I have no preference with regard to what happens to my remains.
IV. HIPAA Release Authority
a. I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 USC § 1320d and 45 CFR Parts 160-164. I authorize any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health-care provider, any insurance company and the Medical Information Bureau Inc. or other health-care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse.
b. The authority given my agent shall supersede any prior agreement that I may have made with my health-care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health-care provider.
c. No individual other than my agent is authorized to receive health information pursuant to HIPAA.
V. Effective Date.
By my initials below, I indicate my choice of Effective Date:
____ This Advance Directive shall take effect in the event I become unable to make my own health care decisions.
____ This Advance Directive will become effective under, or at the time of, the following circumstance(s) or condition(s): _________________________________________.
____ This Advance Directive will become effective upon execution.
VI. Notification of Agent/Location of Original/Ulysses Clause, Etc.
a. The original of this document will be kept by the first health care agent indicated above. Signed photocopies of the original will be given to the following:
Primary Care Clinician:
Attorney: , PO Box 578, Rutland, Vermont 05702-0578
Hospital:
b. I do do not ____ wish to exercise my right to permit my agent to authorize or withhold health care over my objection pursuant to 18 VSA § 9707(h) (“Ulysses Clause”).
c. I do not wish the following individual(s) to act as my health care decision-maker(s); I do not wish my agent to consult with the following individual(s); I do not authorize my agent to provide the following individual(s) my health care information:
_____________________________________________________________________________.
d. To the full extent permitted by law, no one other than my agent may bring an action in the Probate Court pursuant to 18 VSA § 9718 contesting, among other matters, the validity of this Advance Directive.
e. I hereby acknowledge that I have been provided 18 VSA § 9702 setting forth those actions that may be included in an Advance Directive. I understand that the Advance Directive is not and cannot function as a “Do-Not-Resuscitate Order” (DNR), and that a DNR may only be obtained over the signature of a clinician.
IN WITNESS WHEREOF, I have hereunto signed my name this ____ day of _______________, 2010.
_______________________________
Date of Birth: ____________________
We declare that the principal appeared to understand the nature of the Advance Directive and to be free from duress or undue influence at the time the Advance Directive was signed.
Witness: ________________________ Address: __________________________
Witness: ________________________ Address: __________________________
HOSPITAL AND NURSING HOME AFFIRMATION
Statement of ombudsman, hospital representative or other authorized person (to be signed only if the principal is in or is being admitted to a hospital, nursing home or residential care home at the time of execution: 18 VSA 9703(d)):
I declare that I have personally explained the nature and effect of this Advance Directive to the principal and that the principal understands the same.
Date:
Address:
Name:
STATE OF VERMONT )
) ss.:
RUTLAND COUNTY )
At Rutland, Vermont, this ____ day of ______________, 2010,______________, personally appeared and acknowledged this instrument executed by him/her to be his/her free act and deed.
Before me: Notary Public
My Commission Expires:
DISCLOSURE STATEMENT
18 VSA § 9702. ADVANCE DIRECTIVE:
(a) An adult may do any or all of the following in an advance directive:
(1) except as provided in subsection (c), appoint one or more agents and alternate agents to whom authority to make health care decisions is delegated and specify the scope of such authority;
(2) affirm that the agent and alternate agents have been notified of and have accepted the appointment and will be given copies of the advance directive;
(3) specify a circumstance or condition, which may be unrelated to the principal’s capacity, which, when met, makes the authority of an agent effective or ineffective, and may specify the manner in which the condition shall be determined to have been met;
(4) provide that the advance directive will become effective upon execution;
(5) direct the type of health care desired or not desired by the principal, which may include instructions regarding transfer from home, hospitalization, and specific treatments that the principal desires or rejects when being treated for a mental or physical condition or disability;
(6) execute a provision under subsection 9707(h) of this title which permits the agent to authorize or withhold health care over the principal’s objection in the event the principal lacks capacity;
(7) direct which life sustaining treatments, as defined in subdivision (17) of section 9701 of this title, whether emergency, short-term, or long-term, and including nutrition and hydration administered by medical means, are desired or not desired by the principal;
(8) direct which life sustaining treatment the principal would desire or not desire if the principal is pregnant at the time an advance directive becomes effective;
(9) identify those persons whom the principal does not want to serve as his or her decision-maker, or those adults or minors with whom the agent shall or shall not consult or to whom the agent is or is not authorized to provide information regarding the principal’s health care;
(10) identify those interested individuals, otherwise qualified to bring an action under section 9718 of this title, who shall not have authority to bring an action under that section;
(11) authorize release to named individuals in addition to the agent of health information pursuant to HIPAA;
(12) provide any other direction that the principal desires to give regarding the principal’s future health care or personal circumstances;
(13) identify a preferred primary care clinician and affirm that the clinician has been notified;
(14) nominate one or more individuals to serve as the principal’s guardian if a guardian should at some later time need to be appointed, or identify those individuals the principal does not want to serve as guardian;
(15) make, limit, or refuse to make an anatomical gift pursuant to chapter 109 of this title;
(16) direct the manner of disposition of the principal’s remains and the funeral goods and services to be provided;
(17) identify a pre-need contract entered into with a funeral director, crematory, or cemetery; and
(18) except as provided in subsection (d) of this section, appoint an individual to make or refuse to make an anatomical gift, and to arrange for the disposition of the principal’s remains, including funeral goods and services.
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