 | Alaska Medical Power of Attorney Form |
The Alaska medical power of attorney form is a formal document written in advance of an incapacitating illness that states a patient’s choices regarding health care if the patient becomes unable to make decisions for themselves. (See AS 13.52.010) A patient has the right to name an attorney in fact/agent to take over the health care decisions when they are no longer able to do it for themselves. If by chance you (the Principal) fully recover or recover to the point that you may again make your own decisions for your health care, this document may be revoked any time in writing. The principal also has the right to have more than one person overseeing their health care. The document may be as broad or as limited as the principal chooses. If the principal would like to change any of the language in any portion of the document they may do so or if another form is more suitable, it may be used by the principal as long as it complies with AS 13.52. If the principal is not certain about the language in any of the usable documents, they may consider seeking the advice of an attorney that they trust to guide them.
How To Write
Step 1 – Download the document provided. To begin, carefully read and review the “Advanced Health Care Directive Explanation” pages. Inasmuch as this document is extensive, be careful to read all of the paragraphs of information as you proceed from section to section to be certain you understand your rights and the rights of your Attorney(s) In Fact/Agent(s).
Step 2 – Designation of Agent – This section will allow you to name both an Agent and an Alternate Agent to direct your health care in the event you are no longer able to do so. Try to choose agent’s that you are very comfortable with and in discussing your wishes, you feel they will carry them out honorably. Complete all of the fields appropriately as follows:
- Agent 1 provide the following information regarding your first designee:
- Name
- Physical Address
- City
- State
- Zip Code
- Home Phone
- Work Phone
- AND -(The next two designee’s are optional)
- Agent 2 provide the following information regarding your second choice designee:
- Name
- Physical Address
- City
- State
- Zip Code
- Home Phone
- Work Phone
- AND –
- Agent 3 provide the following information regarding your second alternate choice designee:
- Name
- Physical Address
- City
- State
- Zip Code
- Home Phone
- Work Phone
Step 2 – Agent’s Authority – This section will address any specific instruction provided to your agent(s) that will always be in your best interest.
- If you need to make additional information available, you may enter this information on the lines provided.
- If you require more room in this section to be as specific a you can possibly be, add a sheet and attach it to this document.
- It may be a good idea to title the page to be certain that it’s understood what the additions belong to
- Read the next section regarding the definition of “best interest” under this particular authority
Step 3 – When Agent’s Authority Becomes Effective –
- Read the information in this section
- If you would like the authority to become effective immediately, mark the box, if you would prefer to state when authority is effective you may do so, but do NOT check the box if authority is not immediately effective
- Read the next two paragraphs – Agent’s Obligation and Nomination of Guardian. If you would like to change any of this information or the language this is a good time
Step 4 – End of Life Decisions – This section must be read if you (the principal) intend to complete it. As you read it, click the box in front of each desired selection. Your selections are as follows, definitions are contained within each:
- Choice to Prolong Life
- Choice Not to Prolong Life
- A Condition of Permanent Unconsciousness
- A Terminal Condition
- If you have additional instructions to any or all of this section you may enter it into the lines provided. If more room is required, title an added sheet to the section(s) you’re adding to and attach to this document.
- Artificial Nutrition and Hydration – Select from the choices by checking the box in front of your choices – If you have further instructions, place them in the lines provided, adding a titled sheet if needed.
- Relief From Pain – Select from the choices by checking the box in front of your choices – If you have further instructions, place them in the lines provided, adding a titled sheet if needed.
- Should I Become Unconscious and I Am Pregnant – If you have specific instructions, place them in the lines provided, adding a titled sheet if needed.
- Other Wishes. – If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so in the lines provided in this section. Simply place them in the lines provided, adding a titled sheet if needed.
Step 5 – Anatomical Gift – If you are comfortable allowing your agent to make this decision, you may move to the next section. However, if you would like to specify your choice here, you may do so by clicking the box in front of either:
- I give any needed organs, tissues, or other body parts,
- OR
- I give the following organs, tissues, or other body parts only – and then specify, on the line provided, what specific donations you would like to make
Step 6 – Mental Health Treatment – READ CAREFULLY – This entire section is optional. If you choose to make selections regarding mental health treatment, make selections in the following sections by clicking the boxed in front of your options:
- Psychotropic Medications
- Electroconvulsive Treatment
- Admission to and Retention in Facility
- Other Wishes or Instructions – Enter this information into the lines provided. If you have further instructions, place them in the lines provided, adding a titled sheet if needed.
- Conditions or Limitations – Enter this information into the lines provided. If you have further instructions, place them in the lines provided, adding a titled sheet if needed.
Step 7 – Primary Physician (Designation Optional) – If you would like to designate a primary physician provide the following information:
- Name of Physician
- Physical Office Address
- City
- State
- Zip Code
- Phone Number(s)
- If you would like to designate authority for your health care to an alternate primary care physician (also optional) in the event the initial is unable or unwilling to care for you, provide the following:
- Name of Physician
- Physical Office Address
- City
- State
- Zip Code
- Phone Number(s)
Step 8 – Signatures – You (the principal) must have all of the people who will be required to sign this directive, and a notary public, present prior to signing this document. You will need two witnesses either of which may be in any way related by family or employee or be your health care provider. Both witnesses must be well known to you an not be any part of your estate. As well, one of the witnesses may not be related by blood or marriage. All of this is for your protection and an attempt to ensure that everything that happens is truly in your best interest. In the presence of a notary public provide the following:
- The Principal –
- Signature
- Date of signature
- Printed Name
- Address
- City
- State
- Zip
- AND
- The Witnesses – Under your signature information will be paragraphs A and B. These are to be read by you and your witnesses.
- Alternative 1 – May not be related by blood, marriage, be entitled to any part of your estate or in any way in relation to your health care providers. They must then provide –
- Signature of First Witness
- Date
- Printed Name
- Address
- City
- State
- Zip
- AND
- The Witness Who May Be Related To or a Devisee of the Principal must read subsections 1-4 and provide the following:
- Signature of Second Witness
- Date
- Printed Name
- Address
- City
- State
- Zip
Step 9 – Final Notarization
- The notary public must complete this document as witness to all signatures within this document by completing all of the notary required information and then by affixing their state seal.
- The notary will then hand the document to the principal
- Principal must make copies of the document to be provided to all of those who have signed the document as well as to any health care providers or other parties in which the principal would like to share the extent of the information in this document.
- This document may be revoked at any time, in writing, as long as the principal is mentally competent to do so.
