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Hawaii Durable Power of Attorney for Health Care Decisions Form


Hawaii Durable Power of Attorney for Health Care Decisions Form
Hawaii Durable Power of Attorney for Health Care Decisions Form
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Hawaii Durable Power of Attorney for Health Care Decisions
Will to Live Form
DESIGNATION OF AGENT
I, (your name)__________________________________________________________________
(your address)__________________________________________________________________
_____________________________________________________________________________
(your phone number)____________________________________________________________
designate the following individual as my agent to make health-care decisions for me:
(Name of agent)________________________________________________________________
(address of agent)_______________________________________________________________
(phone number(s) of agent)_______________________________________________________
OPTIONAL: If I revoke my agent’s authority, or if my agent is not willing, able, or reasonably
available to make health-care decisions for me, I designate as my first alternate agent:
First Successor Agent
(successor agent’s name)_________________________________________________________
(successor agent’s address)________________________________________________________
_____________________________________________________________________________
(successor agent’s phone number)__________________________________________________
OPTIONAL: If I revoke the authority of my agent and first alternate agent, or if neither is
willing, able, or reasonably available to make health-care decisions for me, I designate as my
second alternate agent:
Second Successor Agent
(second successor agent’s name)___________________________________________________
(second successor agent’s address)__________________________________________________
______________________________________________________________________________
(second successor agent’s phone number)____________________________________________
WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE
My agent’s authority becomes effective when my primary physician determines that I am unable
to make my own health-care decisions unless I mark the following box. If I mark this box, my
agents authority to make health-care decisions for me takes effect immediately.
Hawaii Durable Power of Attorney for Health Care Decisions Form
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