Instructions for Durable Power of Attorney for Health Care
A durable power of attorney for health care is a written document in which you name another person as agent to make health care decisions for you in case you become unable to make or communicate these decisions yourself.
Rhode Island law provides a form for durable power of attorney for health care and requires its exclusive use. If you want to sign one, you should use the form supplied with these instructions.
Please read and follow these instructions carefully.
- Print your name and address on the first two lines of Section 1 of the form.
- Print the name, address, and telephone number of the person you have chosen as your agent. That person may not be associated with your health care provider or community care facility, unless he or she is also your relative.
- You may include in Section 4(a) a statement about your attitudes and general desires concerning medical and surgical treatment, especially life-sustaining care during the final stages of your life.
- If you want to limit your agent's authority to make health care decisions for you, you may do so in Section 4(b).
- If you want your agent's authority to be limited in time, insert the date it should end on the line provided in Section 7.
- If you want to name one or two alternate agents to act on your behalf if your agent is unable, unavailable, or ineligible to make health care decisions for you, you may print their names, addresses, and telephone numbers on the lines provided in Section 8. Alternate agents will act in the order listed.
- Date the form, print the city and state where you are signing it, and then sign your name where indicated before two (2) witnesses who know you and are at least 18 years old.
- Have the two (2) witnesses sign their names and print their names, addresses, and date in the statement of witnesses. Your agent may not be a witness. Also, the witnesses may not be associated with your health care provider or community care facility.
- One of the witnesses must print his or her name and sign the declaration again at the end of the form stating that he or she is not related to you by blood, marriage, or adoption, and is not a potential heir to your estate.
- Give a signed copy of the document to each agent you name and another copy to your physician.
Remember, you may revoke your durable power of attorney for health care at any time simply by telling your physician not to follow it.
Rhode Island Durable Power of Attorney for Health Care
For individual copies of the Rhode Island form for durable power of attorney for health care and living will, call 401-462-3000.