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South Dakota Health Care Power of Attorney Form

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South Dakota Health Care Power of Attorney Form
Health Care Power of Attorney
This is an important legal document. This document designates the person you want to make medical decisions for you in the event you
are unable to participate in your own medical decisions.
Fill out this document carefully. You may want to seek professional help to make sure the form does what you intend and is completed
without mistakes.
This document will be in effect until you revoke it. Read this document from time to time to make sure it still reflects your wishes. You
may change or revoke this document at any time by telling your doctor and other healthcare providers. You should give copies of this
document to your doctor and family. This form is optional. If you choose to use this form, the form has signature lines for you and
either two witnesses, or a notary.
1. Designation of Health Care Agent:
I, ____________________________ hereby appoint: ________________________________________________________
(Agent’s name)
Agent’s Address______________________________________________________________________________________
Agent’s Home phone___________________________________ Agent’s Work Phone______________________________
As my attorney-in-fact (or “Agent”) to make health and personal care decisions for me as authorized in this document.
Effective Date and Durability
By this document I intend to create a durable power of attorney effective upon, and only during, any period of incapacity that, in
the opinion of my Agent and attending doctor, I am not able to make or communicate a choice regarding a particular health-care
2. Agent’s Powers
I grant to my Agent full authority to make decisions for me about my health care. In exercising this authority, my Agent will
consider the recommendation of the attending doctor, the decision I would make if I had decisional capacity, if known, and the
decision that would be in my best interest. I want my Agent to follow my desires as I have state in Section 3.
Accordingly, unless specifically limited by Section 3, below, my Agent is authorized as follows:
A. To consent, refuse or withdraw consent to any and all types of medical care, treatment, surgical procedures, diagnostic
procedures, medication, and use of mechanical or other procedures that affect any bodily function, including (but not limited to)
artificial respiration, nutritional support and hydration, and cardiopulmonary resuscitation;
B. To have access to medical records and information to the same extent that I am entitled, including the right to disclose the
contents to others;
C. To authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care,
assisted living or similar facility or service;
D. To contact on my behalf for any health care related service or facility on my behalf, without my Agent incurring personal financial
liability for such contracts;
E. To hire and fire medical, social service and other support personnel responsible for my care;
F. To authorize, or refuse to authorize, any medicine or procedure intended to relieve pain, even though such use may lead to
physical damage, addiction , or hasten the moment of (but not intentionally cause) my death;
South Dakota Health Care Power of Attorney Form