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DESIGNATION OF ADVOCATE FOR HEALTH CARE DECISIONS
. DESIGNATION OF PATIENT ADVOCATE. I, , of , appoint:
| Patient Advocate Name: |
| Patient Advocate Address: |
| , |
| Phone: | Home: Work: |
| Relation, if any: |
as my Patient Advocate to make health care and personal decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.
. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, when I am unable to participate in medical treatment decisions, I grant my Patient Advocate full power and authority to make care, custody, and medical treatment decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so.
including but NOT including
I specifically authorize my Patient Advocate to make a disposition of a part or parts of my body as he or she deems appropriate.I specifically authorize my Patient Advocate to donate any organs, tissues, or parts upon my death.I specifically authorize my Patient Advocate to donate the following organs, tissues, or parts upon my death: .I specifically authorize my Patient Advocate to donate my entire body upon my death. Any anatomical donation may be used for transplantation only. Any anatomical donation may be used for medical research only. Any anatomical donation may be used for transplantation or medical research. Additional instructions:
In exercising this authority, my Patient Advocate shall act consistently with my desires as stated in this document or otherwise made known to my Patient Advocate. If my desires regarding any particular care, custody or medical treatment decision are not known to my Patient Advocate, then the decision should be made taking into consideration my best interests.
. DURATION. All authority granted to my Patient Advocate shall be exercisable only when I am unable to participate in medical treatment decisions. My attending physician and one other physician or licensed psychologist shall make the determination as to when I am unable to participate in medical treatment decisions, which determination shall be put in writing and made a part of my medical record, and shall be reviewed not less than annually. All powers conferred on my Patient Advocate shall be suspended if I regain the ability to participate in medical treatment decisions. The powers granted to my Patient Advocate shall become effective again if I am later determined unable to participate in medical treatment decisions in the manner described.
SECOND SUCCESSOR PATIENT ADVOCATE
| Patient Advocate Name: |
| Address: |
| , |
| Phone: | Home: Work: |
. GENERAL PROVISIONS
1. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
2. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
3. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
(YOU MUST DATE AND SIGN THIS DOCUMENT)
I have read and understand the contents of this document and the effect of this grant of powers to my Patient Advocate. I am at least eighteen years old, and am providing these instructions of my free will. I am emotionally and mentally competent to make this declaration.
Signed on _____ day of _______________, _____.
| Signature: | ________________________________________ |
| Name: |
| Address: |
| County |
TO BE EFFECTIVE THIS DOCUMENT MUST BE SIGNED IN THE PRESENCE OF TWO WITNESSES.
STATEMENT OF WITNESSES
We declare that the person who signed this Document, , is personally known to us, that he/she signed this document in our presence, and that he/she appeared to us to be of sound mind and under no duress, fraud or undue influence. We are not the spouse, parent, child, grandchild, sibling, physician, presumptive heir, or known beneficiary of the will at the time of witnessing of the person who signed this instrument. We are not named as the Patient Advocate or a Successor Patient Advocate in this document. Nor are we an employee of a life or health insurance provider for, or an employee for a health facility that is treating, the person who signed this instrument, nor are we an employee of a home for the aged where the person who signed this instrument resides. We are at least eighteen years old.
| Witness Signature: | ________________________________________ |
Date: _________________________
| Witness Signature: | _________________________________________ |
Date: ________________________
PATIENT ADVOCATE ACCEPTANCE OF DESIGNATION
The Patient Advocate/Successor Patient Advocate(s) accept(s) the Patient's designation as stated in this document and agree(s) that:
a. This designation shall not become effective unless the Patient is unable to participate in medical treatment decisions.
b. A Patient Advocate shall not exercise powers concerning the Patient's care, custody, and medical treatment that the Patient, if the Patient were able to participate in the decision, could not have exercised on his or her own behalf.
c. This designation cannot be used to make a medical treatment to withhold or withdraw treatment from a Patient who is pregnant that would result in the pregnant Patient's death.
d. A Patient Advocate may make a decision to withhold or withdraw treatment which would allow a patient to die only if the Patient has expressed in a clear and convincing manner that the Patient Advocate is authorized to make such a decision, and that the Patient acknowledges that such a decision could or would allow the Patient's death.
e. A Patient Advocate shall not receive compensation for the performance of his or her authority, rights, and responsibilities, but a Patient Advocate may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities.
f. A Patient Advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the Patient and shall act consistent with the Patient's best interest. The known desires of the Patient expressed or evidenced while the Patient is able to participate in medical treatment decisions are presumed to be in the Patient's best interests.
g. A Patient may revoke his or her designation at any time and in any manner sufficient to communicate an intent to revoke.
h. A Patient Advocate may revoke his or her acceptance to the designation at any time and in any manner sufficient to communicate an intent to revoke.
i. A Patient admitted to a health facility or agency has the rights enumerated in Section 20201 of the Public Health Code, Act No. 368 of Public Acts of 1978, being Section 333.20201 of the Michigan Compiled Laws.
________________________________________
PATIENT ADVOCATE
| _____ | Your First Successor Patient Advocate, , must sign this form. |
| _____ | Your Second Successor Patient Advocate, , must sign this form. |
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It is fast and easy to grant or obtain the support you need with a free Michigan Medical Power of Attorney template from Rocket Lawyer:
This solution, in most cases, would end up being notably less expensive and less time-consuming than hiring and working with the average law firm. If necessary, you may start this Medical PoA on behalf of an elderly parent, a spouse, or another relative, and then have them sign it once you've drafted it. Keep in mind that for this document to be considered valid, the principal must be mentally competent when they sign. If the principal is already unable to make their own decisions, a court-appointed conservatorship may be required. In such a situation, it's important for you to talk to a lawyer .
Every person over 18 years old ought to have a Medical Power of Attorney. Even though it can be difficult to acknowledge, there could come a day when you can no longer make your own medical decisions. Here are a few typical occasions where you might consider power of attorney to be useful:
Regardless of whether your Michigan Medical Power of Attorney has been produced in response to an emergency or as part of a long-term plan, notarization and/or witnesses can help to protect your agent if anyone challenges their privileges and authority.
Sometimes, in researching the topics of elder care and estate planning, you may see "healthcare power of attorney", "medical power of attorney" and "healthcare proxy" being used interchangeably. In short, they are one and the same. That being said, please keep in mind that it's absolutely possible to get agency over matters that are not health-related, in which case, "proxy" is not normally used.
Michigan Medical PoA forms are typically straightforward; however, you or your agent(s) might still have legal questions. Having a lawyer look over your document may take a lot of time if you attempt to do it on your own. An easier approach would be through Rocket Lawyer attorney services. Rocket Lawyer members are able to request advice from an experienced lawyer or send other questions. As always, you can be confident that Rocket Lawyer is here by your side.
The cost of hiring an attorney to generate a Medical Power of Attorney can total between two hundred and five hundred dollars, depending on your location. Rocket Lawyer offers much more than many other Power of Attorney template providers that you might come across elsewhere. As a Rocket Lawyer member, you can get up to a 40% discount when hiring an attorney.
Each Power of Attorney comes with its own series of tips on what you should do next. You are encouraged to try any or all of these actions related to your PoA: editing it, saving it in PDF format or as a Word file, printing it out, and/or signing it. Finally, take care to give a final copy of the signed document to your agent(s) and care providers.
The specific requirements and restrictions governing PoA forms will be different in each state; however, in Michigan, your Power of Attorney must be signed by two witnesses. Witnesses must not include your physician, any employees of your life or health insurance provider, or employees of a healthcare facility where you are a patient. Relatives (including your spouse), heirs, and any other beneficiaries are also prohibited. As a basic principle, witnesses will need to be over 18 years old, and none of them should simultaneously be your Power of Attorney agent.
See Michigan Medical/Healthcare Power of Attorney law: § 700.5507
