2006 Minnesota Statutes

CHAPTER 145C. HEALTH CARE DIRECTIVES

145C.01 DEFINITIONS.
    Subdivision 1. Applicability. The definitions in this section apply to this chapter.
    Subd. 1a. Act in good faith. "Act in good faith" means to act consistently with a legally
sufficient health care directive of the principal, a living will executed under chapter 145B,
a declaration regarding intrusive mental health treatment executed under section 253B.03,
subdivision 6d , or information otherwise made known by the principal, unless the actor has actual
knowledge of the modification or revocation of the information expressed. If these sources of
information do not provide adequate guidance to the actor, "act in good faith" means acting in
the best interests of the principal, considering the principal's overall general health condition and
prognosis and the principal's personal values to the extent known. Notwithstanding any instruction
of the principal, a health care agent, health care provider, or any other person is not acting in good
faith if the person violates the provisions of section 609.215 prohibiting assisted suicide.
    Subd. 1b. Decision-making capacity. "Decision-making capacity" means the ability to
understand the significant benefits, risks, and alternatives to proposed health care and to make and
communicate a health care decision.
    Subd. 2. Health care agent. "Health care agent" means an individual age 18 or older who
is appointed by a principal in a health care power of attorney to make health care decisions on
behalf of the principal. "Health care agent" may also be referred to as "agent."
    Subd. 3. Health care power of attorney. "Health care power of attorney" means an
instrument appointing one or more health care agents to make health care decisions for the
principal.
    Subd. 4. Health care. "Health care" means any care, treatment, service, or procedure to
maintain, diagnose, or otherwise affect a person's physical or mental condition. "Health care"
includes the provision of nutrition or hydration parenterally or through intubation but does not
include any treatment, service, or procedure that violates the provisions of section 609.215
prohibiting assisted suicide. "Health care" also includes the establishment of a person's abode
within or without the state and personal security safeguards for a person, to the extent decisions
on these matters relate to the health care needs of the person.
    Subd. 5. Health care decision. "Health care decision" means the consent, refusal of consent,
or withdrawal of consent to health care.
    Subd. 5a. Health care directive. "Health care directive" means a written instrument that
complies with section 145C.03 and includes one or more health care instructions, a health
care power of attorney, or both; or a durable power of attorney for health care executed under
this chapter before August 1, 1998.
    Subd. 6. Health care provider. "Health care provider" means a person, health care facility,
organization, or corporation licensed, certified, or otherwise authorized or permitted by the laws
of this state to administer health care directly or through an arrangement with other health care
providers, including health maintenance organizations licensed under chapter 62D.
    Subd. 7. Health care facility. "Health care facility" means a hospital or other entity licensed
under sections 144.50 to 144.58, a nursing home licensed to serve adults under section 144A.02, a
home care provider licensed under sections 144A.43 to 144A.47, an adult foster care provider
licensed under chapter 245A and Minnesota Rules, parts 9555.5105 to 9555.6265, or a hospice
provider licensed under sections 144A.75 to 144A.755.
    Subd. 7a. Health care instruction. "Health care instruction" means a written statement of
the principal's values, preferences, guidelines, or directions regarding health care.
    Subd. 8. Principal. "Principal" means an individual age 18 or older who has executed a
health care directive.
    Subd. 9. Reasonably available. "Reasonably available" means able to be contacted and
willing and able to act in a timely manner considering the urgency of the principal's health care
needs.
History: 1993 c 312 s 2; 1998 c 254 art 1 s 36; 1998 c 399 s 3-11; 2002 c 252 s 20,24;
2004 c 288 art 6 s 16

145C.02 HEALTH CARE DIRECTIVE.
A principal with the capacity to do so may execute a health care directive. A health care
directive may include one or more health care instructions to direct health care providers, others
assisting with health care, family members, and a health care agent. A health care directive
may include a health care power of attorney to appoint a health care agent to make health
care decisions for the principal when the principal, in the judgment of the principal's attending
physician, lacks decision-making capacity, unless otherwise specified in the health care directive.
History: 1993 c 312 s 3; 1998 c 399 s 12

145C.03 REQUIREMENTS.
    Subdivision 1. Legal sufficiency. To be legally sufficient in this state, a health care directive
must:
(1) be in writing;
(2) be dated;
(3) state the principal's name;
(4) be executed by a principal with capacity to do so with the signature of the principal or
with the signature of another person authorized by the principal to sign on behalf of the principal;
(5) contain verification of the principal's signature or the signature of the person authorized
by the principal to sign on behalf of the principal, either by a notary public or by witnesses
as provided under this chapter; and
(6) include a health care instruction, a health care power of attorney, or both.
    Subd. 2. Individuals ineligible to act as health care agent. (a) An individual appointed by
the principal under section 145C.05, subdivision 2, paragraph (b), to make the determination of
the principal's decision-making capacity is not eligible to act as the health care agent.
(b) The following individuals are not eligible to act as the health care agent, unless the
individual appointed is related to the principal by blood, marriage, registered domestic partnership,
or adoption, or unless the principal has otherwise specified in the health care directive:
(1) a health care provider attending the principal on the date of execution of the health care
directive or on the date the health care agent must make decisions for the principal; or
(2) an employee of a health care provider attending the principal on the date of execution of
the health care directive or on the date the health care agent must make decisions for the principal.
    Subd. 3. Individuals ineligible to act as witnesses or notary public. (a) A health care
agent or alternate health care agent appointed in a health care power of attorney may not act as
a witness or notary public for the execution of the health care directive that includes the health
care power of attorney.
(b) At least one witness to the execution of the health care directive must not be a health care
provider providing direct care to the principal or an employee of a health care provider providing
direct care to the principal on the date of execution. A person notarizing a health care directive
may be an employee of a health care provider providing direct care to the principal.
History: 1993 c 312 s 4; 1998 c 399 s 13

145C.04 EXECUTED IN ANOTHER STATE.
(a) A health care directive or similar document executed in another state or jurisdiction is
legally sufficient under this chapter if it:
(1) complies with the law of the state or jurisdiction in which it was executed; or
(2) complies with section 145C.03.
(b) Nothing in this section shall be interpreted to authorize a directive or similar document to
override the provisions of section 609.215 prohibiting assisted suicide.
History: 1993 c 312 s 5; 1998 c 399 s 14

145C.05 SUGGESTED FORM.
    Subdivision 1. Content. A health care directive executed pursuant to this chapter may, but
need not, be in the form contained in section 145C.16.
    Subd. 2. Provisions that may be included. (a) A health care directive may include
provisions consistent with this chapter, including, but not limited to:
(1) the designation of one or more alternate health care agents to act if the named health
care agent is not reasonably available to serve;
(2) directions to joint health care agents regarding the process or standards by which the
health care agents are to reach a health care decision for the principal, and a statement whether
joint health care agents may act independently of one another;
(3) limitations, if any, on the right of the health care agent or any alternate health care agents
to receive, review, obtain copies of, and consent to the disclosure of the principal's medical
records;
(4) limitations, if any, on the nomination of the health care agent as guardian for purposes
of sections 524.5-202, 524.5-211, 524.5-302, and 524.5-303;
(5) a document of gift for the purpose of making an anatomical gift, as set forth in sections
525.921 to 525.9224, or an amendment to, revocation of, or refusal to make an anatomical gift;
(6) a declaration regarding intrusive mental health treatment under section 253B.03,
subdivision 6d , or a statement that the health care agent is authorized to give consent for the
principal under section 253B.04, subdivision 1a;
(7) a funeral directive as provided in section 149A.80, subdivision 2;
(8) limitations, if any, to the effect of dissolution or annulment of marriage or termination
of domestic partnership on the appointment of a health care agent under section 145C.09,
subdivision 2 ;
(9) specific reasons why a principal wants a health care provider or an employee of a health
care provider attending the principal to be eligible to act as the principal's health care agent;
(10) health care instructions by a woman of child bearing age regarding how she would like
her pregnancy, if any, to affect health care decisions made on her behalf; and
(11) health care instructions regarding artificially administered nutrition or hydration.
(b) A health care directive may include a statement of the circumstances under which the
directive becomes effective other than upon the judgment of the principal's attending physician
in the following situations:
(1) a principal who in good faith generally selects and depends upon spiritual means or
prayer for the treatment or care of disease or remedial care and does not have an attending
physician, may include a statement appointing an individual who may determine the principal's
decision-making capacity; and
(2) a principal who in good faith does not generally select a physician or a health care facility
for the principal's health care needs may include a statement appointing an individual who may
determine the principal's decision-making capacity, provided that if the need to determine the
principal's capacity arises when the principal is receiving care under the direction of an attending
physician in a health care facility, the determination must be made by an attending physician after
consultation with the appointed individual.
If a person appointed under clause (1) or (2) is not reasonably available and the principal is
receiving care under the direction of an attending physician in a health care facility, an attending
physician shall determine the principal's decision-making capacity.
(c) A health care directive may authorize a health care agent to make health care decisions
for a principal even though the principal retains decision-making capacity.
History: 1993 c 312 s 6; 1995 c 211 s 2; 1998 c 399 s 15,16; 2004 c 146 art 3 s 3

145C.06 WHEN EFFECTIVE.
A health care directive is effective for a health care decision when:
(1) it meets the requirements of section 145C.03, subdivision 1; and
(2) the principal, in the determination of the attending physician of the principal, lacks
decision-making capacity to make the health care decision; or if other conditions for effectiveness
otherwise specified by the principal have been met.
A health care directive is not effective for a health care decision when the principal, in the
determination of the attending physician of the principal, recovers decision-making capacity; or if
other conditions for effectiveness otherwise specified by the principal have been met.
History: 1993 c 312 s 7; 1998 c 399 s 17

145C.07 AUTHORITY AND DUTIES OF HEALTH CARE AGENT.
    Subdivision 1. Authority. The health care agent has authority to make any particular health
care decision only if the principal lacks decision-making capacity, in the determination of the
attending physician, to make or communicate that health care decision; or if other conditions for
effectiveness otherwise specified by the principal have been met. The physician or other health
care provider shall continue to obtain the principal's informed consent to all health care decisions
for which the principal has decision-making capacity, unless other conditions for effectiveness
otherwise specified by the principal have been met. An alternate health care agent has authority to
act if the primary health care agent is not reasonably available to act.
    Subd. 2. Health care agent as guardian. Unless the principal has otherwise specified in
the health care directive, the appointment of the health care agent in a health care directive is
considered a nomination of a guardian for purposes of sections 524.5-101 to 524.5-502.
    Subd. 3. Duties. In exercising authority under a health care directive, a health care agent has
a duty to act in good faith. A health care agent or any alternate health care agent has a personal
obligation to the principal to make health care decisions authorized by the health care power of
attorney, but this obligation does not constitute a legal duty to act.
    Subd. 4. Inconsistencies among documents. In the event of inconsistency between the
appointment of a proxy under chapter 145B or section 253B.03, subdivision 6d, or of a health
care agent under this chapter, the most recent appointment takes precedence. In the event of
other inconsistencies among documents executed under this chapter, under chapter 145B, or
under sections 253B.03, subdivision 6d, or 524.5-101 to 524.5-502, or other legally sufficient
documents, the provisions of the most recently executed document take precedence only to the
extent of the inconsistency.
History: 1993 c 312 s 8; 1998 c 399 s 18; 2004 c 146 art 3 s 4,5

145C.08 AUTHORITY TO REVIEW MEDICAL RECORDS.
A health care agent acting pursuant to a health care directive has the same right as the
principal to receive, review, and obtain copies of medical records of the principal, and to consent
to the disclosure of medical records of the principal, unless the principal has otherwise specified
in the health care directive.
History: 1993 c 312 s 9; 1998 c 399 s 19

145C.09 REVOCATION OF HEALTH CARE DIRECTIVE.
    Subdivision 1. Revocation. A principal with the capacity to do so may revoke a health care
directive in whole or in part at any time by doing any of the following:
(1) canceling, defacing, obliterating, burning, tearing, or otherwise destroying the health care
directive instrument or directing another in the presence of the principal to destroy the health care
directive instrument, with the intent to revoke the health care directive in whole or in part;
(2) executing a statement, in writing and dated, expressing the principal's intent to revoke
the health care directive in whole or in part;
(3) verbally expressing the principal's intent to revoke the health care directive in whole or in
part in the presence of two witnesses who do not have to be present at the same time; or
(4) executing a subsequent health care directive, to the extent the subsequent instrument is
inconsistent with any prior instrument.
    Subd. 2. Effect of dissolution, annulment, or termination of domestic partnership.
Unless the principal has otherwise specified in the health care directive, the appointment by the
principal of the principal's spouse or registered domestic partner as health care agent under a
health care power of attorney is revoked by the commencement of proceedings for dissolution,
annulment, or termination of the principal's marriage or commencement of proceedings for
termination of the principal's registered domestic partnership.
    Subd. 3. Power of a guardian. The powers of a guardian to revoke the appointment of a
health care agent in a health care directive of which the ward is the principal or to revoke the
health care directive itself are specified in section 524.5-315.
History: 1993 c 312 s 10; 1998 c 399 s 20; 2003 c 12 art 2 s 1

145C.10 PRESUMPTIONS.
(a) The principal is presumed to have the capacity to execute a health care directive and to
revoke a health care directive, absent clear and convincing evidence to the contrary.
(b) A health care provider or health care agent may presume that a health care directive is
legally sufficient absent actual knowledge to the contrary. A health care directive is presumed to
be properly executed, absent clear and convincing evidence to the contrary.
(c) A health care agent, and a health care provider acting pursuant to the direction of a
health care agent, are presumed to be acting in good faith, absent clear and convincing evidence
to the contrary.
(d) A health care directive is presumed to remain in effect until the principal modifies or
revokes it, absent clear and convincing evidence to the contrary.
(e) This chapter does not create a presumption concerning the intention of an individual who
has not executed a health care directive and, except as otherwise provided by section 145C.15,
does not impair or supersede any right or responsibility of an individual to consent, refuse to
consent, or withdraw consent to health care on behalf of another in the absence of a health care
directive.
(f) A copy of a health care directive is presumed to be a true and accurate copy of the
executed original, absent clear and convincing evidence to the contrary, and must be given the
same effect as an original.
(g) When a patient lacks decision-making capacity and is pregnant, and in reasonable medical
judgment there is a real possibility that if health care to sustain her life and the life of the fetus is
provided the fetus could survive to the point of live birth, the health care provider shall presume
that the patient would have wanted such health care to be provided, even if the withholding or
withdrawal of such health care would be authorized were she not pregnant. This presumption
is negated by health care directive provisions described in section 145C.05, subdivision 2,
paragraph (a), clause (10), that are to the contrary, or, in the absence of such provisions, by clear
and convincing evidence that the patient's wishes, while competent, were to the contrary.
History: 1993 c 312 s 11; 1998 c 399 s 21

145C.11 IMMUNITIES.
    Subdivision 1. Health care agent. A health care agent is not subject to criminal prosecution
or civil liability if the health care agent acts in good faith.
    Subd. 2. Health care provider. (a) With respect to health care provided to a patient with a
health care directive, a health care provider is not subject to criminal prosecution, civil liability, or
professional disciplinary action if the health care provider acts in good faith and in accordance
with applicable standards of care.
(b) A health care provider is not subject to criminal prosecution, civil liability, or professional
disciplinary action if the health care provider relies on a health care decision made by the health
care agent and the following requirements are satisfied:
(1) the health care provider believes in good faith that the decision was made by a health
care agent appointed to make the decision and has no actual knowledge that the health care
directive has been revoked; and
(2) the health care provider believes in good faith that the health care agent is acting in
good faith.
(c) A health care provider who administers health care necessary to keep the principal alive,
despite a health care decision of the health care agent to withhold or withdraw that treatment, is
not subject to criminal prosecution, civil liability, or professional disciplinary action if that health
care provider promptly took all reasonable steps to:
(1) notify the health care agent of the health care provider's unwillingness to comply;
(2) document the notification in the principal's medical record; and
(3) permit the health care agent to arrange to transfer care of the principal to another health
care provider willing to comply with the decision of the health care agent.
History: 1993 c 312 s 12; 1998 c 399 s 22

145C.12 PROHIBITED PRACTICES.
    Subdivision 1. Health care provider. A health care provider, health care service plan,
insurer, self-insured employee welfare benefit plan, or nonprofit hospital plan may not condition
admission to a facility, or the providing of treatment or insurance, on the requirement that an
individual execute a health care directive.
    Subd. 2. Insurance. A policy of life insurance is not legally impaired or invalidated in any
manner by the withholding or withdrawing of health care pursuant to the direction of a health
care agent appointed pursuant to this chapter, or pursuant to the implementation of health care
instructions under this chapter.
History: 1993 c 312 s 13; 1998 c 399 s 23

145C.13 PENALTIES.
    Subdivision 1. Gross misdemeanor offenses. Whoever commits any of the following acts
is guilty of a gross misdemeanor:
(1) willfully conceals, cancels, defaces, or obliterates a health care directive of a principal
without the consent of the principal;
(2) willfully conceals or withholds personal knowledge of a revocation of a health care
directive;
(3) falsifies or forges a health care directive or a revocation of the instrument;
(4) coerces or fraudulently induces another to execute a health care directive; or
(5) requires or prohibits the execution of a health care directive as a condition for being
insured for or receiving all or some health care services.
    Subd. 2. Felony offenses. Whoever commits an act prohibited under subdivision 1 is guilty
of a felony if the act results in bodily harm to the principal or to the person who would have been
a principal but for the unlawful act.
History: 1993 c 312 s 14; 1998 c 399 s 25

145C.14 CERTAIN PRACTICES NOT CONDONED.
Nothing in this chapter may be construed to condone, authorize, or approve mercy killing or
euthanasia.
History: 1993 c 312 s 15

145C.15 DUTY TO PROVIDE LIFE-SUSTAINING HEALTH CARE.
(a) If a proxy acting under chapter 145B or a health care agent acting under this chapter
directs the provision of health care, nutrition, or hydration that, in reasonable medical judgment,
has a significant possibility of sustaining the life of the principal or declarant, a health care
provider shall take all reasonable steps to ensure the provision of the directed health care,
nutrition, or hydration if the provider has the legal and actual capability of providing the health
care either itself or by transferring the principal or declarant to a health care provider who has that
capability. Any transfer of a principal or declarant under this paragraph must be done promptly
and, if necessary to preserve the life of the principal or declarant, by emergency means. This
paragraph does not apply if a living will under chapter 145B or a health care directive indicates
an intention to the contrary.
(b) A health care provider who is unwilling to provide directed health care under paragraph
(a) that the provider has the legal and actual capability of providing may transfer the principal
or declarant to another health care provider willing to provide the directed health care but the
provider shall take all reasonable steps to ensure provision of the directed health care until the
principal or declarant is transferred.
(c) Nothing in this section alters any legal obligation or lack of legal obligation of a health
care provider to provide health care to a principal or declarant who refuses, has refused, or is
unable to pay for the health care.
History: 1993 c 312 s 16; 1998 c 399 s 26

145C.16 SUGGESTED FORM.
The following is a suggested form of a health care directive and is not a required form.

HEALTH CARE DIRECTIVE

I, ..........................., understand this document allows me to do ONE OR BOTH of the
following:
PART I: Name another person (called the health care agent) to make health care decisions
for me if I am unable to decide or speak for myself. My health care agent must make health
care decisions for me based on the instructions I provide in this document (Part II), if any, the
wishes I have made known to him or her, or must act in my best interest if I have not made my
health care wishes known.
AND/OR
PART II: Give health care instructions to guide others making health care decisions for me. If
I have named a health care agent, these instructions are to be used by the agent. These instructions
may also be used by my health care providers, others assisting with my health care and my family,
in the event I cannot make decisions for myself.

PART I: APPOINTMENT OF HEALTH CARE AGENT

THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS
FOR ME IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF
(I know I can change my agent or alternate agent at any time and I know I do not have
to appoint an agent or an alternate agent)
NOTE: If you appoint an agent, you should discuss this health care directive with your agent
and give your agent a copy. If you do not wish to appoint an agent, you may leave Part I blank
and go to Part II.
When I am unable to decide or speak for myself, I trust and appoint .......................... to make
health care decisions for me. This person is called my health care agent.
Relationship of my health care agent to me:

---

Telephone number of my health care agent:

---

Address of my health care agent:

---

(OPTIONAL) APPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my health
care agent is not reasonably available, I trust and appoint .................... to be my health care
agent instead.
Relationship of my alternate health care agent to me:

---

Telephone number of my alternate health care agent:

---

Address of my alternate health care agent:

---

THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO

DO IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF
(I know I can change these choices)
My health care agent is automatically given the powers listed below in (A) through (D).
My health care agent must follow my health care instructions in this document or any other
instructions I have given to my agent. If I have not given health care instructions, then my agent
must act in my best interest.
Whenever I am unable to decide or speak for myself, my health care agent has the power to:
(A) Make any health care decision for me. This includes the power to give, refuse, or
withdraw consent to any care, treatment, service, or procedures. This includes deciding whether
to stop or not start health care that is keeping me or might keep me alive, and deciding about
intrusive mental health treatment.
(B) Choose my health care providers.
(C) Choose where I live and receive care and support when those choices relate to my
health care needs.
(D) Review my medical records and have the same rights that I would have to give my
medical records to other people.
If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR
if I want to LIMIT any power in (A) through (D), I MUST say that here:
My health care agent is NOT automatically given the powers listed below in (1) and (2). If I
WANT my agent to have any of the powers in (1) and (2), I must INITIAL the line in front of the
power; then my agent WILL HAVE that power.

			(1)		To decide whether to donate any parts of my body, including organs, tissues, and eyes, when I die.
			(2)		To decide what will happen with my body when I die (burial, cremation).

If I want to say anything more about my health care agent's powers or limits on the powers, I
can say it here:

PART II: HEALTH CARE INSTRUCTIONS

NOTE: Complete this Part II if you wish to give health care instructions. If you appointed an agent
in Part I, completing this Part II is optional but would be very helpful to your agent. However,
if you chose not to appoint an agent in Part I, you MUST complete some or all of this Part II if
you wish to make a valid health care directive.
These are instructions for my health care when I am unable to decide or speak for myself.
These instructions must be followed (so long as they address my needs).

THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE

(I know I can change these choices or leave any of them blank)
I want you to know these things about me to help you make decisions about my health care:

	My goals for my health care:
	My fears about my health care:
	My spiritual or religious beliefs and traditions:
	My beliefs about when life would be no longer worth living:
	My thoughts about how my medical condition might affect my family:

THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE

(I know I can change these choices or leave any of them blank)
Many medical treatments may be used to try to improve my medical condition or to prolong
my life. Examples include artificial breathing by a machine connected to a tube in the lungs,
artificial feeding or fluids through tubes, attempts to start a stopped heart, surgeries, dialysis,
antibiotics, and blood transfusions. Most medical treatments can be tried for a while and then
stopped if they do not help.
I have these views about my health care in these situations:
(Note: You can discuss general feelings, specific treatments, or leave any of them blank)

	If I had a reasonable chance of recovery, and were temporarily unable to decide or speak for myself, I would want:
	If I were dying and unable to decide or speak for myself, I would want:
	If I were permanently unconscious and unable to decide or speak for myself, I would want:
	If I were completely dependent on others for my care and unable to decide or speak for myself, I would want:
	In all circumstances, my doctors will try to keep me comfortable and reduce my pain. This is how I feel about pain relief if it would affect my alertness or if it could shorten my life:

There are other things that I want or do not want for my health care, if possible:

	Who I would like to be my doctor:
	Where I would like to live to receive health care:
	Where I would like to die and other wishes I have about dying:
	My wishes about donating parts of my body when I die:
	My wishes about what happens to my body when I die (cremation, burial):
	Any other things:

PART III: MAKING THE DOCUMENT LEGAL

This document must be signed by me. It also must either be verified by a notary public
(Option 1) OR witnessed by two witnesses (Option 2). It must be dated when it is verified or
witnessed.
I am thinking clearly, I agree with everything that is written in this document, and I have
made this document willingly.

	My Signature
		Date signed:
		Date of birth:
		Address:

If I cannot sign my name, I can ask someone to sign this document for me.
Signature of the person who I asked to sign this document for me.
Printed name of the person who I asked to sign this document for me.

Option 1: Notary Public

In my presence on .................... (date), ....................... (name) acknowledged his/her
signature on this document or acknowledged that he/she authorized the person signing this
document to sign on his/her behalf. I am not named as a health care agent or alternate health
care agent in this document.

	(Signature of Notary)	(Notary Stamp)

Option 2: Two Witnesses

Two witnesses must sign. Only one of the two witnesses can be a health care provider or an
employee of a health care provider giving direct care to me on the day I sign this document.
Witness One:
(i) In my presence on ............... (date), ............... (name) acknowledged his/her signature
on this document or acknowledged that he/she authorized the person signing this document to
sign on his/her behalf.
(ii) I am at least 18 years of age.
(iii) I am not named as a health care agent or an alternate health care agent in this document.
(iv) If I am a health care provider or an employee of a health care provider giving direct
care to the person listed above in (A), I must initial this box: [ ]
I certify that the information in (i) through (iv) is true and correct.

	(Signature of Witness One)
	Address:

Witness Two:
(i) In my presence on .............. (date), ................. (name) acknowledged his/her signature
on this document or acknowledged that he/she authorized the person signing this document to
sign on his/her behalf.
(ii) I am at least 18 years of age.
(iii) I am not named as a health care agent or an alternate health care agent in this document.
(iv) If I am a health care provider or an employee of a health care provider giving direct
care to the person listed above in (A), I must initial this box: [ ]
I certify that the information in (i) through (iv) is true and correct.

	(Signature of Witness Two)
	Address:

REMINDER: Keep this document with your personal papers in a safe place (not in a safe deposit
box). Give signed copies to your doctors, family, close friends, health care agent, and alternate
health care agent. Make sure your doctor is willing to follow your wishes. This document should
be part of your medical record at your physician's office and at the hospital, home care agency,
hospice, or nursing facility where you receive your care.
History: 1998 c 399 s 24; 1999 c 14 s 1