 | Rhode Island Medical Power of Attorney Form |
The Rhode Island Medical Power of Attorney form is a legal document that protects the rights of a Principal when it’s time to make end of life decisions. As long as the Principal makes this document available to an Agent of their selection and make the document available to any health care provider with whom the Principal utilizes their services, the Principal’s wishes will be honored. It is the Agent’s duty to honor the Principal’s health care wishes every step of the way.
Until the Principal is no longer able to communicate their wishes on their own, the Principal shall remain in control of their health care. It is strongly suggested, that if the Principal is uncertain of the language contained within this document, that they consult with an attorney to clarify the document entirely.
This document must be signed in the service of a Notary Public OR Two qualified witnesses. The document may be revoked at any time that the Principal wishes to do so. Notification must be provided in writing and must be served or delivered to the Agent(s)
How to Write
1 – Introduction and Principal’s Rights
The Principal should not skip over any portion of the information provided in this document. Begin by reviewing the following titled sections:
- Your Rights
- What is a Durable Power of Attorney for Health Care?
- Remember
2 – Durable Powers and Advanced Directive
The Principal shall initiate the document by providing the following information. Remember to read all of the information in each section:
- Establish the owner of the document by entering the full name and complete address of the Principal on the first blank space
- Review the entire paragraph in this section
3 – Appointment of Health Care Agent
Prior to appointing the Agent, be certain to read 1 through 4 so that it will be understood those who must be eliminated from the appointment process. Once the eligibility of the Attorney-in-Fact has been verified the first paragraph will need some information to be provided:
- Enter the name of the selected Agent
- Provide the Agent’s telephone number
- Submit the complete address of the Agent
4 – Optional selection of Successor Agent’s
Begin by reading the introduction to selecting successor Agent’s. You may select two according to this document. Before recording your selection, once the Principal has completed reading the information, provide the Principal’s initials at the bottom right of the page.
- Enter each Successor Agent’s full name
- Report each Successor Agent’s telephone number
- Document the complete addresses for each Agent
5 – Information Regarding the Principal’s Powers Granted
- The Principal must carefully review all of the information in the paragraphs
- Read the protective information in statements 1,2 and 3
- The Principal must review a list of typical Health Care Agent Powers (Statements A through H). Each statement defines the powers granted to the Health Care Agent through this form’s execution
- If the Principal wishes to limit and/or restrict any of the powers listed, this must be indicated on the blank lines below the statement beginning with “If I DO NOT want …” List the Letter of the Statement being forbidden or restricted then state what the Health Care Agent may or may not do.
- For example: “(D), My agent may not choose my health care providers” or “(D), My agent may only choose my health care provider under such and such circumstance.” The Principal is encouraged to be very specific if/when supplying this information (if more room is required, this may be continued on a titled, signed, and dated attachment)
- Once this section is completed, initial the right bottom of the page
6 – Do(s)and Do Not(s) Regarding Health Care Preferences
Read the titled section with regard to life support options
7 – Optional – For Discussion (with Agent) Purposes
Completion of this section may assist your Agent and health care providers in making decisions when the Principal is no longer able to do so.
- Read each statement, 1 through 5, and provide answers in the lines provided under each statement
8 – Principal’s Preferences in the Event of Advanced Illness
- The Principal may assist his or her Agent and health care providers by reading each statement 1 through 3 and initialing their preferences
- The Principal may make any additional information available on the lines provide and may add continued information if so desired
9 – Organ Donation
- The Principal may read each statement and initial his or her Principals approval on the blank space corresponding to that statement when it applies.
10 – Religious and Spiritual Requests
- In the event that the Principal would like to have a spiritual advisor in the event they become ill, initial yes or no and provide:
- The name of the Spiritual Advisor
- The complete address of the advisor
- The advisor’s telephone number(s)
11 – Duration
- If the Principal would like the duration of the document to revoke on a specific date, enter that date of expiration in mm/dd/yyyy format
- Read the following three titles –
- Revocation
- Making the Document Legal
12 – Date and Signature of Principal
To be signed before a Notary Public OR Two qualified witnesses –
- The Principal must read the statement prior to provision of signature
- The Principal must enter their full name signature
- Date the signature in mm/dd/yyyy format
13 – Witness Option
The Principal Shall Select the Form of Witnessing of the Document. If the option will be the two witnesses, the following must be provided:
- Witnesses Respective Signatures
- Printed Names of Witnesses
- Witnesses Residential Addresses
- Dates of Signatures and Information in mm/dd/yyyy format
- OR
- Should a Notary be the Principal’s selection, the Notary will complete this section with their required information
14 – Principal’s Acknowledgement of Witnesses
- The Principal must read the statement and provide signature and print their name acknowledging each eligible witness or a single notary
15 – Distribution of The Document
The Principal must read the statement provided – If the Principal chooses to distribute the document beyond the Agent and keeping the original for their own records:
- Check each box to indicate to whom the Principal would like to provide copy of this document
- For each checked box, provide:
- The recipient’s name
- Complete Address
- Telephone Number
16 – Additional Principal Instruction Information
- Should the Principal choose to make available, further wishes, medical decisions, religious information etc… they may enter this information into this page entirely
- Once complete, enter the Principal’s initials at the bottom right of the page
17 – Commonly Used Life Support Measures
The Principal should read the titled sections on this page as follows:
- Cardiopulmonary Resuscitation (CPR)
- Mechanical Ventilation
- Artificial Nutrition and Hydration
