Free Healthcare Proxy Template

DESIGNATION OF HEALTHCARE AGENT

I, Margaret Anne Sullivan, born April 12, 1952, residing at 742 Evergreen Terrace, Springfield, IL 62701, State of California, being of sound mind and understanding the nature of this document, hereby designate Daniel Patrick Sullivan, my Spouse, of 742 Evergreen Terrace, Springfield, IL 62701 ((217) 555-0143 · daniel.sullivan@email.com), as my Healthcare Agent and Attorney-in-Fact for all healthcare decisions (hereinafter "Agent"). My Agent is authorized to act on my behalf in all matters relating to my health, medical care, and treatment decisions as set forth herein.

GRANT OF AUTHORITY

Subject to the limitations set forth herein, my Agent is specifically authorized to:

  (a) make all healthcare decisions on my behalf, including consenting to, refusing, or withdrawing consent to any medical procedure, treatment, or intervention, including life-sustaining treatment;

  (b) admit, transfer, or discharge me from any hospital, nursing facility, hospice, or other healthcare facility;

  (c) hire, instruct, compensate, and discharge physicians, nurses, and other healthcare providers acting on my behalf;

  (d) access my medical records, test results, diagnoses, and treatment information from any healthcare provider, hospital, or facility;

  (e) make decisions about my care, comfort, and quality of life;

  (f) make decisions regarding mental health treatment, including voluntary admission to inpatient psychiatric facilities and consent to or refusal of psychiatric medications or therapies, to the extent permitted by the laws of California;

  (g) take all other actions reasonably necessary to carry out my healthcare wishes as expressed herein or as otherwise known to my Agent.

My Agent's authority under this document is as broad as I am permitted to grant and shall be construed liberally to accomplish my healthcare goals. Third parties may rely on my Agent's representations without independent investigation.

INCAPACITY STANDARD AND EFFECTIVENESS

This Healthcare Proxy shall become effective upon a written determination by my attending physician (or, where permitted by state law, a licensed clinical psychologist or nurse practitioner) that I lack sufficient capacity to make or communicate healthcare decisions. Such determination shall be documented in my medical record and shall state the nature, cause, and probable duration of my incapacity. My Agent's authority shall cease if I regain decision-making capacity. Until a formal determination of incapacity is made, I retain full authority over all of my healthcare decisions.

END-OF-LIFE TREATMENT DIRECTIVES (LIVING WILL)

In accordance with the constitutionally protected liberty interest in refusing unwanted medical treatment recognized in In re Quinlan, 70 N.J. 10 (1976), and Cruzan v. Director, Mo. Dep't of Health, 497 U.S. 261 (1990) (confirming that a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment and permitting states to require clear-and-convincing evidence of an incompetent person's wishes), and the applicable laws of California (including any state-adopted provisions of the Uniform Health-Care Decisions Act (UHCDA) and state analogs, such as Cal. Prob. Code §§4600-4805; N.Y. Pub. Health Law §§2980-2994; Mass. Gen. Laws ch. 201D; Fla. Stat. §§765.101-.546; Tex. Health and Safety Code §§166.001-.210), I provide the following specific instructions regarding life-sustaining treatment. These instructions shall apply when I have an irreversible condition from which there is no reasonable expectation of recovery, including terminal illness, permanent unconsciousness, or end-stage irreversible decline:

  (a) Resuscitation: I DO NOT WANT cardiopulmonary resuscitation (CPR), defibrillation, or resuscitative measures. If my heart stops or I stop breathing, allow natural death to occur without intervention. This instruction shall be communicated to my treating physician for appropriate clinical orders.

  (b) Mechanical Ventilation: I DO NOT WANT to be placed on mechanical ventilation. If I am already receiving ventilator support and my attending physician and Agent agree there is no reasonable expectation of recovery of meaningful function, I authorize its removal.

  (c) Artificial Nutrition and Hydration: I DO NOT WANT artificial nutrition or hydration through feeding tubes or intravenous lines if I cannot eat or drink on my own and my condition is irreversible. I understand and accept that withholding such treatment may shorten my life, and I make this choice freely and knowingly pursuant to my constitutional right recognized in Cruzan v. Director, Mo. Dep't of Health, 497 U.S. 261 (1990).

  (d) Dialysis: I delegate the decision regarding dialysis to my Healthcare Agent.

  (e) Pain Management and Comfort Care: I want maximum comfort care, including aggressive palliative and pain-management measures consistent with hospice standards of care, even if such measures may incidentally hasten my death. My primary goal is relief from pain and suffering, not prolongation of life.

Clinical Note: These preferences are advance-directive instructions for my Agent and treating physicians. They do not substitute for a physician-signed DNR / DNAR order or a Physician/Medical Orders for Life-Sustaining Treatment (POLST / MOLST) form as authorized under the law of California. My Agent should work with my treating physician to execute appropriate clinical orders consistent with these instructions. Pregnancy Note: Several states impose statutory limitations on the withholding or withdrawing of life-sustaining treatment from a pregnant patient; the enforceability of such limitations remains subject to state law and evolving constitutional analysis following Dobbs v. Jackson Women's Health Org., 597 U.S. 215 (2022). My Agent and treating physicians should consult California law to determine what portions of these instructions are given effect during any pregnancy.

HIPAA AUTHORIZATION - PERSONAL REPRESENTATIVE

I hereby designate my Healthcare Agent as my Personal Representative for all purposes under the Health Insurance Portability and Accountability Act of 1996 (HIPAA, 42 U.S.C. §1320d et seq.) and its Privacy Rule implementing regulations at 45 C.F.R. §164.502(g)(1)-(3) (personal-representative access to PHI) and 45 C.F.R. §164.524 (right of access). Pursuant to this designation, I authorize and direct all physicians, hospitals, clinics, laboratories, pharmacies, health plans, and other covered entities and business associates to disclose to my Agent any and all Protected Health Information (PHI) concerning me, including:

  - medical records, diagnoses, test results, imaging, pathology, laboratory data, and treatment plans;
  - billing records and insurance information to the extent necessary to make or implement healthcare decisions;
  - records from prior, current, and future healthcare providers;
  - records concerning mental-health diagnoses and treatment (other than separately maintained psychotherapy notes under 45 C.F.R. §164.508(a)(2)); substance-use disorder records protected under 42 C.F.R. Part 2; and HIV/AIDS status records to the extent permitted by applicable state law.

This HIPAA Authorization is effective immediately upon my signature and shall remain in effect until revoked in writing. It is not limited to periods of incapacity. Any healthcare provider relying in good faith on this authorization shall be held harmless. This authorization does not extend to separately maintained psychotherapy notes as defined at 45 C.F.R. §164.501 unless a separate, compliant authorization is executed.

SUCCESSOR HEALTHCARE AGENT

If Daniel Patrick Sullivan (my primary Healthcare Agent) is deceased, mentally incapacitated, unwilling to serve, or unreachable at a time when healthcare decisions must be made, I hereby appoint Catherine Lynn Sullivan, my Daughter, of 210 Oak Street, Chicago, IL 60601 ((312) 555-0289) as my Successor Healthcare Agent with the same authority and subject to the same obligations as the primary Agent. The Successor Agent assumes authority only upon written confirmation of the primary Agent's inability or unwillingness to serve, or upon the treating physician's written certification that the primary Agent cannot be reached within a clinically appropriate time period.

POST-DEATH DIRECTIVES

  (a) Organ and Tissue Donation: I consent to the donation of the following specific organs and tissues upon my death: heart, kidneys, liver. This gift is made pursuant to the Revised Uniform Anatomical Gift Act (UAGA 2006) as adopted in California, for the purposes of transplantation, therapy, research, and education. No organs or tissues other than those listed above are donated.

  (b) Remains: I prefer that my remains be disposed of by cremation.

  (c) Additional Instructions: I would like a simple memorial service at Holy Name Cathedral. I wish my ashes to be placed at Rosehill Cemetery.

DUTIES AND STANDARDS OF THE HEALTHCARE AGENT

My Agent shall: (a) act in my best interest and consistent with my known values, religious beliefs, and expressed wishes; (b) make healthcare decisions as I would make them if I were able; (c) consult with my treating physicians and other healthcare professionals to obtain relevant medical information; (d) keep my healthcare information confidential and disclose it only as necessary to carry out my wishes; (e) not make decisions motivated by the Agent's personal convenience or financial gain; and (f) document significant healthcare decisions where practicable. My Agent shall be immune from civil or criminal liability for healthcare decisions made in good faith and consistent with the terms of this document.

REVOCATION

I may revoke this Healthcare Proxy at any time while I retain decision-making capacity, by: (a) executing a new Healthcare Proxy; (b) notifying my Agent or treating physician orally or in writing; or (c) physically destroying this document. Revocation is effective upon communication to my Agent or any treating healthcare provider. A subsequent Healthcare Proxy automatically revokes all prior Healthcare Proxies unless it expressly provides otherwise. Healthcare providers who act in good faith reliance on this document prior to receiving written notice of revocation shall be held harmless.

GOVERNING LAW AND VALIDITY

This Healthcare Proxy is intended to comply with the federal Patient Self-Determination Act of 1990, 42 U.S.C. §§1395cc(f) and 1396a(w), and with the laws of the State of California, including any applicable provisions of the Uniform Health-Care Decisions Act (UHCDA) or state-specific analog, such as Cal. Prob. Code §§4600-4805; N.Y. Pub. Health Law §§2980-2994 (Health Care Agents and Proxies); Mass. Gen. Laws ch. 201D (Health Care Proxies); Fla. Stat. §§765.101-.546 (Health Care Advance Directives); and Tex. Health and Safety Code §§166.001-.210 (Advance Directives Act). If any provision of this document is held invalid or unenforceable under applicable state law, the remaining provisions shall continue in full force and effect. If I receive healthcare in a state other than California, this document shall be honored to the fullest extent permitted by the laws of that state and any applicable interstate-recognition provisions.