§ 32A‑25.1. Statutoryform health care power of attorney.
(a) The use of thefollowing form in the creation of a health care power of attorney is lawfuland, when used, it shall meet the requirements of and be construed inaccordance with the provisions of this Article:
HEALTH CARE POWER OF ATTORNEY
NOTE: YOU SHOULD USE THISDOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE AGENT IF YOU ARE COMFORTABLEGIVING THAT PERSON BROAD AND SWEEPING POWERS TO MAKE HEALTH CARE DECISIONS FORYOU. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A HEALTH CARE POWER OFATTORNEY.
EXPLANATION: You havethe right to name someone to make health care decisions for you when you cannotmake or communicate those decisions. This form may be used to create a healthcare power of attorney, and meets the requirements of North Carolina law.However, you are not required to use this form, and North Carolina law allowsthe use of other forms that meet certain requirements. If you prepare your ownhealth care power of attorney, you should be very careful to make sure it isconsistent with North Carolina law.
Thisdocument gives the person you designate as your health care agent broadpowers to make health care decisions for you when you cannot make thedecision yourself or cannot communicate your decision to other people. Youshould discuss your wishes concerning life‑prolonging measures, mentalhealth treatment, and other health care decisions with your health care agent.Except to the extent that you express specific limitations or restrictions inthis form, your health care agent may make any health care decision you couldmake yourself.
Thisform does not impose a duty on your health care agent to exercise grantedpowers, but when a power is exercised, your health care agent will be obligatedto use due care to act in your best interests and in accordance with thisdocument.
ThisHealth Care Power of Attorney form is intended to be valid in any jurisdictionin which it is presented, but places outside North Carolina may impose requirementsthat this form does not meet.
Ifyou want to use this form, you must complete it, sign it, and have yoursignature witnessedby twoqualified witnessesand proved by a notary public. Follow theinstructions about which choices you can initial very carefully. Do not signthis form until two witnesses and a notary public are present to watch yousign it. You then should give a copy to your health care agent and to anyalternates you name. You should consider filing it with the Advance Health CareDirective Registry maintained by the North Carolina Secretary of State: https://www.nclifelinks.org/ahcdr/
1. Designation of HealthCare Agent.
I, __________________, being ofsound mind, hereby appoint the following person(s) to serve as my health careagent(s) to act for me and in my name (in any way I could act in person) tomake health care decisions for me as authorized in this document. My designatedhealth care agent(s) shall serve alone, in the order named.
A. Name: _______________________ HomeTelephone: _______________
Home Address: _______________________ WorkTelephone: _______________
Any successor health care agentdesignated shall be vested with the same power and duties as if originallynamed as my health care agent, and shall serve any time his or her predecessoris not reasonably available or is unwilling or unable to serve in thatcapacity.
2. Effectiveness ofAppointment.
My designation of a health careagent expires only when I revoke it. Absent revocation, the authority grantedin this document shall become effective when and if one of the physician(s)listed below determines that I lack capacity to make or communicate decisionsrelating to my health care, and will continue in effect during that incapacity,or until my death, except if I authorize my health care agent to exercise myrights with respect to anatomical gifts, autopsy, or disposition of my remains,this authority will continue after my death to the extent necessary to exercisethat authority.
1. _______________________ (Physician)
2. _______________________ (Physician)
If I have not designated aphysician, or no physician(s) named above is reasonably available, thedetermination that I lack capacity to make or communicate decisions relating tomy health care shall be made by my attending physician.
3. Revocation.
Any time while I am competent, Imay revoke this power of attorney in a writing I sign or by communicating myintent to revoke, in any clear and consistent manner, to my health care agentor my health care provider.
4. General Statement ofAuthority Granted.
Subject to any restrictions setforth in Section 5 below, I grant to my health care agent full power andauthority to make and carry out all health care decisions for me. Thesedecisions include, but are not limited to:
A. Requesting,reviewing, and receiving any information, verbal or written, regarding myphysical or mental health, including, but not limited to, medical and hospitalrecords, and to consent to the disclosure of this information.
B. Employing ordischarging my health care providers.
C. Consenting to andauthorizing my admission to and discharge from a hospital, nursing orconvalescent home, hospice, long‑term care facility, or other health carefacility.
D. Consenting to andauthorizing my admission to and retention in a facility for the care ortreatment of mental illness.
E. Consenting to andauthorizing the administration of medications for mental health treatment andelectroconvulsive treatment (ECT) commonly referred to as "shocktreatment."
F. Giving consent for,withdrawing consent for, or withholding consent for, X‑ray, anesthesia,medication, surgery, and all other diagnostic and treatment procedures orderedby or under the authorization of a licensed physician, dentist, podiatrist, orother health care provider. This authorization specifically includes the powerto consent to measures for relief of pain.
G. Authorizing thewithholding or withdrawal of life‑prolonging measures.
H. Providing my medicalinformation at the request of any individual acting as my attorney‑in‑factunder a durable power of attorney or as a Trustee or successor Trustee underany Trust Agreement of which I am a Grantor or Trustee, or at the request ofany other individual whom my health care agent believes should have suchinformation. I desire that such information be provided whenever it wouldexpedite the prompt and proper handling of my affairs or the affairs of anyperson or entity for which I have some responsibility. In addition, I authorizemy health care agent to take any and all legal steps necessary to ensurecompliance with my instructions providing access to my protected healthinformation. Such steps shall include resorting to any and all legal proceduresin and out of courts as may be necessary to enforce my rights under the law andshall include attempting to recover attorneys' fees against anyone who does notcomply with this health care power of attorney.
I. To the extent Ihave not already made valid and enforceable arrangements during my lifetimethat have not been revoked, exercising any right I may have to authorize anautopsy or direct the disposition of my remains.
J. Taking any lawfulactions that may be necessary to carry out these decisions, including, but notlimited to: (i) signing, executing, delivering, and acknowledging anyagreement, release, authorization, or other document that may be necessary,desirable, convenient, or proper in order to exercise and carry out any ofthese powers; (ii) granting releases of liability to medical providers orothers; and (iii) incurring reasonable costs on my behalf related to exercisingthese powers, provided that this health care power of attorney shall not givemy health care agent general authority over my property or financial affairs.
5. Special Provisions andLimitations.
(Notice: The authority grantedin this document is intended to be as broad as possible so that your healthcare agent will have authority to make any decisions you could make to obtainor terminate any type of health care treatment or service. If you wish to limitthe scope of your health care agent's powers, you may do so in this section. Ifnone of the following are initialed, there will be no special limitations onyour agent's authority.)
A. Limitationsabout Artificial Nutrition or Hydration: In exercising the authority to makehealth care decisions on my behalf, my health care agent:
______________ shallNOT have the authority to withhold artificial nutrition (Initial) (such as through tubes) OR mayexercise that authority only in accordance with the followingspecial provisions:
______________ shallNOT have the authority to withhold artificial hydration (Initial) (such as through tubes) OR mayexercise that authority only in accordance with the followingspecial provisions:
NOTE: If you initial either block but do not insert any special provisions, yourhealth care agent shall have NO AUTHORITY to withhold artificial nutrition orhydration.
______________ B. LimitationsConcerning Health Care Decisions. In exercising (Initial) the authority to make healthcare decisions on my behalf, the authority of my health care agentis subject to the following special provisions: (Here you mayinclude any specific provisions you deem appropriatesuch as: your own definition of when life‑prolonging measuresshould be withheld or discontinued, or instructions torefuse any specific types of treatment that are inconsistentwith your religious beliefs, or are unacceptable to you for anyother reason.)
NOTE: DO NOT initial unless you insert a limitation.
______________ C. LimitationsConcerning Mental Health Decisions. In (Initial) exercising the authority tomake mental health decisions on my behalf, the authority of myhealth care agent is subject to the following special provisions:(Here you may include any specific provisions you deemappropriate such as: limiting the grant of authority to makeonly mental health treatment decisions, your own instructionsregarding the administration or withholding of psychotropicmedications and electroconvulsive treatment (ECT),instructions regarding your admission to and retention ina health care facility for mental health treatment, orinstructions to refuse any specific types of treatment that areunacceptable to you.)
NOTE: DO NOT initial unless you insert a limitation.
______________ D. AdvanceInstruction for Mental Health Treatment. (Notice: (Initial) This health care power ofattorney may incorporate or be combined with an advanceinstruction for mental health treatment, executed in accordancewith Part 2 of Article 3 of Chapter 122C of the GeneralStatutes, which you may use to state your instructions regardingmental health treatment in the event you lack capacity tomake or communicate mental health treatment decisions. Becauseyour health care agent's decisions must be consistent withany statements you have expressed in an advanceinstruction, you should indicate here whether you have executed anadvance instruction for mental health treatment):
NOTE: DO NOT initial unless you insert a limitation.
______________ E. Autopsyand Disposition of Remains. In exercising the (Initial) authority to make decisionsregarding autopsy and disposition of remains on my behalf, theauthority of my health care agent is subject to the followingspecial provisions and limitations. (Here you may include any specificlimitations you deem appropriate such as: limiting thegrant of authority and the scope of authority, orinstructions regarding burial or cremation):
NOTE: DO NOT initial unless you insert a limitation.
6. Organ Donation.
To the extent I have not alreadymade valid and enforceable arrangements during my lifetime that have not beenrevoked, my health care agent may exercise any right I may have to:
______________ donateany needed organs or parts; or
(Initial)
______________ donateonly the following organs or parts:
______________ donatemy body for anatomical study if needed.
(Initial)
______________ Inexercising the authority to make donations, my health care (Initial) agent is subject to thefollowing special provisions and limitations: (Here you may includeany specific limitations you deem appropriate such as:limiting the grant of authority and the scope of authority, orinstructions regarding gifts of the body or body parts.)
NOTE: DO NOT initial unless you insert a limitation.
NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN THIS INSTRUMENT WITHOUT YOURINITIALS.
7. Guardianship Provision.
If it becomes necessary for acourt to appoint a guardian of my person, I nominate the persons designated inSection 1, in the order named, to be the guardian of my person, to servewithout bond or security. The guardian shall act consistently withG.S. 35A‑1201(a)(5).
8. Reliance of ThirdParties on Health Care Agent.
A. No person who reliesin good faith upon the authority of or any representations by my health careagent shall be liable to me, my estate, my heirs, successors, assigns, orpersonal representatives, for actions or omissions in reliance on thatauthority or those representations.
B. The powers conferredon my health care agent by this document may be exercised by my health careagent alone, and my health care agent's signature or action taken under theauthority granted in this document may be accepted by persons as fullyauthorized by me and with the same force and effect as if I were personallypresent, competent, and acting on my own behalf. All acts performed in goodfaith by my health care agent pursuant to this power of attorney are done withmy consent and shall have the same validity and effect as if I were present andexercised the powers myself, and shall inure to the benefit of and bind me, myestate, my heirs, successors, assigns, and personal representatives. Theauthority of my health care agent pursuant to this power of attorney shall besuperior to and binding upon my family, relatives, friends, and others.
9.Miscellaneous Provisions.
A. Revocation of PriorPowers of Attorney. I revoke any prior health care power of attorney. Thepreceding sentence is not intended to revoke any general powers of attorney,some of the provisions of which may relate to health care; however, this powerof attorney shall take precedence over any health care provisions in any validgeneral power of attorney I have not revoked.
B. Jurisdiction,Severability, and Durability. This Health Care Power of Attorney is intended tobe valid in any jurisdiction in which it is presented. The powers delegatedunder this power of attorney are severable, so that the invalidity of one ormore powers shall not affect any others. This power of attorney shall not beaffected or revoked by my incapacity or mental incompetence.
C. Health Care Agent NotLiable. My health care agent and my health care agent's estate, heirs,successors, and assigns are hereby released and forever discharged by me, myestate, my heirs, successors, assigns, and personal representatives from allliability and from all claims or demands of all kinds arising out of my healthcare agent's acts or omissions, except for my health care agent's willfulmisconduct or gross negligence.
D. No Civil or CriminalLiability. No act or omission of my health care agent, or of any other person,entity, institution, or facility acting in good faith in reliance on theauthority of my health care agent pursuant to this Health Care Power ofAttorney shall be considered suicide, nor the cause of my death for any civilor criminal purposes, nor shall it be considered unprofessional conduct or aslack of professional competence. Any person, entity, institution, or facilityagainst whom criminal or civil liability is asserted because of conductauthorized by this Health Care Power of Attorney may interpose this document asa defense.
E. Reimbursement. Myhealth care agent shall be entitled to reimbursement for all reasonableexpenses incurred as a result of carrying out any provision of this directive.
By signing here, I indicate thatI am mentally alert and competent, fully informed as to the contents of this document,and understand the full import of this grant of powers to my health care agent.
This the _____ day of______________, 20____.
________________________(SEAL)
I hereby state that theprincipal, _______________, being of sound mind, signed (or directed another tosign on the principal's behalf) the foregoing health care power of attorney inmy presence, and that I am not related to the principal by blood or marriage,and I would not be entitled to any portion of the estate of the principal underany existing will or codicil of the principal or as an heir under the IntestateSuccession Act, if the principal died on this date without a will. I also statethat I am not the principal's attending physician, nor a licensed health careprovider or mental health treatment provider who is (1) an employee of theprincipal's attending physician or mental health treatment provider, (2) anemployee of the health facility in which the principal is a patient, or (3) anemployee of a nursing home or any adult care home where the principal resides.I further state that I do not have any claim against the principal or theestate of the principal.
(b) Use of thestatutory form prescribed in this section is an optional and nonexclusivemethod for creating a health care power of attorney and does not affect the useof other forms of health care powers of attorney, including previous statutoryforms. (1991, c.639, s. 1; 1993, c. 523, s. 3; 1998‑198, s. 1; 1998‑217, s. 53;2005‑351, s. 3; 2006‑226, s. 32; 2007‑502, s. 6(b); 2008‑187,s. 37(a).)
§ 32A‑25.1. Statutoryform health care power of attorney.
(a) The use of thefollowing form in the creation of a health care power of attorney is lawfuland, when used, it shall meet the requirements of and be construed inaccordance with the provisions of this Article:
HEALTH CARE POWER OF ATTORNEY
NOTE: YOU SHOULD USE THISDOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE AGENT IF YOU ARE COMFORTABLEGIVING THAT PERSON BROAD AND SWEEPING POWERS TO MAKE HEALTH CARE DECISIONS FORYOU. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A HEALTH CARE POWER OFATTORNEY.
EXPLANATION: You havethe right to name someone to make health care decisions for you when you cannotmake or communicate those decisions. This form may be used to create a healthcare power of attorney, and meets the requirements of North Carolina law.However, you are not required to use this form, and North Carolina law allowsthe use of other forms that meet certain requirements. If you prepare your ownhealth care power of attorney, you should be very careful to make sure it isconsistent with North Carolina law.
Thisdocument gives the person you designate as your health care agent broadpowers to make health care decisions for you when you cannot make thedecision yourself or cannot communicate your decision to other people. Youshould discuss your wishes concerning life‑prolonging measures, mentalhealth treatment, and other health care decisions with your health care agent.Except to the extent that you express specific limitations or restrictions inthis form, your health care agent may make any health care decision you couldmake yourself.
Thisform does not impose a duty on your health care agent to exercise grantedpowers, but when a power is exercised, your health care agent will be obligatedto use due care to act in your best interests and in accordance with thisdocument.
ThisHealth Care Power of Attorney form is intended to be valid in any jurisdictionin which it is presented, but places outside North Carolina may impose requirementsthat this form does not meet.
Ifyou want to use this form, you must complete it, sign it, and have yoursignature witnessedby twoqualified witnessesand proved by a notary public. Follow theinstructions about which choices you can initial very carefully. Do not signthis form until two witnesses and a notary public are present to watch yousign it. You then should give a copy to your health care agent and to anyalternates you name. You should consider filing it with the Advance Health CareDirective Registry maintained by the North Carolina Secretary of State: https://www.nclifelinks.org/ahcdr/
1. Designation of HealthCare Agent.
I, __________________, being ofsound mind, hereby appoint the following person(s) to serve as my health careagent(s) to act for me and in my name (in any way I could act in person) tomake health care decisions for me as authorized in this document. My designatedhealth care agent(s) shall serve alone, in the order named.
A. Name: _______________________ HomeTelephone: _______________
Home Address: _______________________ WorkTelephone: _______________
Any successor health care agentdesignated shall be vested with the same power and duties as if originallynamed as my health care agent, and shall serve any time his or her predecessoris not reasonably available or is unwilling or unable to serve in thatcapacity.
2. Effectiveness ofAppointment.
My designation of a health careagent expires only when I revoke it. Absent revocation, the authority grantedin this document shall become effective when and if one of the physician(s)listed below determines that I lack capacity to make or communicate decisionsrelating to my health care, and will continue in effect during that incapacity,or until my death, except if I authorize my health care agent to exercise myrights with respect to anatomical gifts, autopsy, or disposition of my remains,this authority will continue after my death to the extent necessary to exercisethat authority.
1. _______________________ (Physician)
2. _______________________ (Physician)
If I have not designated aphysician, or no physician(s) named above is reasonably available, thedetermination that I lack capacity to make or communicate decisions relating tomy health care shall be made by my attending physician.
3. Revocation.
Any time while I am competent, Imay revoke this power of attorney in a writing I sign or by communicating myintent to revoke, in any clear and consistent manner, to my health care agentor my health care provider.
4. General Statement ofAuthority Granted.
Subject to any restrictions setforth in Section 5 below, I grant to my health care agent full power andauthority to make and carry out all health care decisions for me. Thesedecisions include, but are not limited to:
A. Requesting,reviewing, and receiving any information, verbal or written, regarding myphysical or mental health, including, but not limited to, medical and hospitalrecords, and to consent to the disclosure of this information.
B. Employing ordischarging my health care providers.
C. Consenting to andauthorizing my admission to and discharge from a hospital, nursing orconvalescent home, hospice, long‑term care facility, or other health carefacility.
D. Consenting to andauthorizing my admission to and retention in a facility for the care ortreatment of mental illness.
E. Consenting to andauthorizing the administration of medications for mental health treatment andelectroconvulsive treatment (ECT) commonly referred to as "shocktreatment."
F. Giving consent for,withdrawing consent for, or withholding consent for, X‑ray, anesthesia,medication, surgery, and all other diagnostic and treatment procedures orderedby or under the authorization of a licensed physician, dentist, podiatrist, orother health care provider. This authorization specifically includes the powerto consent to measures for relief of pain.
G. Authorizing thewithholding or withdrawal of life‑prolonging measures.
H. Providing my medicalinformation at the request of any individual acting as my attorney‑in‑factunder a durable power of attorney or as a Trustee or successor Trustee underany Trust Agreement of which I am a Grantor or Trustee, or at the request ofany other individual whom my health care agent believes should have suchinformation. I desire that such information be provided whenever it wouldexpedite the prompt and proper handling of my affairs or the affairs of anyperson or entity for which I have some responsibility. In addition, I authorizemy health care agent to take any and all legal steps necessary to ensurecompliance with my instructions providing access to my protected healthinformation. Such steps shall include resorting to any and all legal proceduresin and out of courts as may be necessary to enforce my rights under the law andshall include attempting to recover attorneys' fees against anyone who does notcomply with this health care power of attorney.
I. To the extent Ihave not already made valid and enforceable arrangements during my lifetimethat have not been revoked, exercising any right I may have to authorize anautopsy or direct the disposition of my remains.
J. Taking any lawfulactions that may be necessary to carry out these decisions, including, but notlimited to: (i) signing, executing, delivering, and acknowledging anyagreement, release, authorization, or other document that may be necessary,desirable, convenient, or proper in order to exercise and carry out any ofthese powers; (ii) granting releases of liability to medical providers orothers; and (iii) incurring reasonable costs on my behalf related to exercisingthese powers, provided that this health care power of attorney shall not givemy health care agent general authority over my property or financial affairs.
5. Special Provisions andLimitations.
(Notice: The authority grantedin this document is intended to be as broad as possible so that your healthcare agent will have authority to make any decisions you could make to obtainor terminate any type of health care treatment or service. If you wish to limitthe scope of your health care agent's powers, you may do so in this section. Ifnone of the following are initialed, there will be no special limitations onyour agent's authority.)
A. Limitationsabout Artificial Nutrition or Hydration: In exercising the authority to makehealth care decisions on my behalf, my health care agent:
______________ shallNOT have the authority to withhold artificial nutrition (Initial) (such as through tubes) OR mayexercise that authority only in accordance with the followingspecial provisions:
______________ shallNOT have the authority to withhold artificial hydration (Initial) (such as through tubes) OR mayexercise that authority only in accordance with the followingspecial provisions:
NOTE: If you initial either block but do not insert any special provisions, yourhealth care agent shall have NO AUTHORITY to withhold artificial nutrition orhydration.
______________ B. LimitationsConcerning Health Care Decisions. In exercising (Initial) the authority to make healthcare decisions on my behalf, the authority of my health care agentis subject to the following special provisions: (Here you mayinclude any specific provisions you deem appropriatesuch as: your own definition of when life‑prolonging measuresshould be withheld or discontinued, or instructions torefuse any specific types of treatment that are inconsistentwith your religious beliefs, or are unacceptable to you for anyother reason.)
NOTE: DO NOT initial unless you insert a limitation.
______________ C. LimitationsConcerning Mental Health Decisions. In (Initial) exercising the authority tomake mental health decisions on my behalf, the authority of myhealth care agent is subject to the following special provisions:(Here you may include any specific provisions you deemappropriate such as: limiting the grant of authority to makeonly mental health treatment decisions, your own instructionsregarding the administration or withholding of psychotropicmedications and electroconvulsive treatment (ECT),instructions regarding your admission to and retention ina health care facility for mental health treatment, orinstructions to refuse any specific types of treatment that areunacceptable to you.)
NOTE: DO NOT initial unless you insert a limitation.
______________ D. AdvanceInstruction for Mental Health Treatment. (Notice: (Initial) This health care power ofattorney may incorporate or be combined with an advanceinstruction for mental health treatment, executed in accordancewith Part 2 of Article 3 of Chapter 122C of the GeneralStatutes, which you may use to state your instructions regardingmental health treatment in the event you lack capacity tomake or communicate mental health treatment decisions. Becauseyour health care agent's decisions must be consistent withany statements you have expressed in an advanceinstruction, you should indicate here whether you have executed anadvance instruction for mental health treatment):
NOTE: DO NOT initial unless you insert a limitation.
______________ E. Autopsyand Disposition of Remains. In exercising the (Initial) authority to make decisionsregarding autopsy and disposition of remains on my behalf, theauthority of my health care agent is subject to the followingspecial provisions and limitations. (Here you may include any specificlimitations you deem appropriate such as: limiting thegrant of authority and the scope of authority, orinstructions regarding burial or cremation):
NOTE: DO NOT initial unless you insert a limitation.
6. Organ Donation.
To the extent I have not alreadymade valid and enforceable arrangements during my lifetime that have not beenrevoked, my health care agent may exercise any right I may have to:
______________ donateany needed organs or parts; or
(Initial)
______________ donateonly the following organs or parts:
______________ donatemy body for anatomical study if needed.
(Initial)
______________ Inexercising the authority to make donations, my health care (Initial) agent is subject to thefollowing special provisions and limitations: (Here you may includeany specific limitations you deem appropriate such as:limiting the grant of authority and the scope of authority, orinstructions regarding gifts of the body or body parts.)
NOTE: DO NOT initial unless you insert a limitation.
NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN THIS INSTRUMENT WITHOUT YOURINITIALS.
7. Guardianship Provision.
If it becomes necessary for acourt to appoint a guardian of my person, I nominate the persons designated inSection 1, in the order named, to be the guardian of my person, to servewithout bond or security. The guardian shall act consistently withG.S. 35A‑1201(a)(5).
8. Reliance of ThirdParties on Health Care Agent.
A. No person who reliesin good faith upon the authority of or any representations by my health careagent shall be liable to me, my estate, my heirs, successors, assigns, orpersonal representatives, for actions or omissions in reliance on thatauthority or those representations.
B. The powers conferredon my health care agent by this document may be exercised by my health careagent alone, and my health care agent's signature or action taken under theauthority granted in this document may be accepted by persons as fullyauthorized by me and with the same force and effect as if I were personallypresent, competent, and acting on my own behalf. All acts performed in goodfaith by my health care agent pursuant to this power of attorney are done withmy consent and shall have the same validity and effect as if I were present andexercised the powers myself, and shall inure to the benefit of and bind me, myestate, my heirs, successors, assigns, and personal representatives. Theauthority of my health care agent pursuant to this power of attorney shall besuperior to and binding upon my family, relatives, friends, and others.
9.Miscellaneous Provisions.
A. Revocation of PriorPowers of Attorney. I revoke any prior health care power of attorney. Thepreceding sentence is not intended to revoke any general powers of attorney,some of the provisions of which may relate to health care; however, this powerof attorney shall take precedence over any health care provisions in any validgeneral power of attorney I have not revoked.
B. Jurisdiction,Severability, and Durability. This Health Care Power of Attorney is intended tobe valid in any jurisdiction in which it is presented. The powers delegatedunder this power of attorney are severable, so that the invalidity of one ormore powers shall not affect any others. This power of attorney shall not beaffected or revoked by my incapacity or mental incompetence.
C. Health Care Agent NotLiable. My health care agent and my health care agent's estate, heirs,successors, and assigns are hereby released and forever discharged by me, myestate, my heirs, successors, assigns, and personal representatives from allliability and from all claims or demands of all kinds arising out of my healthcare agent's acts or omissions, except for my health care agent's willfulmisconduct or gross negligence.
D. No Civil or CriminalLiability. No act or omission of my health care agent, or of any other person,entity, institution, or facility acting in good faith in reliance on theauthority of my health care agent pursuant to this Health Care Power ofAttorney shall be considered suicide, nor the cause of my death for any civilor criminal purposes, nor shall it be considered unprofessional conduct or aslack of professional competence. Any person, entity, institution, or facilityagainst whom criminal or civil liability is asserted because of conductauthorized by this Health Care Power of Attorney may interpose this document asa defense.
E. Reimbursement. Myhealth care agent shall be entitled to reimbursement for all reasonableexpenses incurred as a result of carrying out any provision of this directive.
By signing here, I indicate thatI am mentally alert and competent, fully informed as to the contents of this document,and understand the full import of this grant of powers to my health care agent.
This the _____ day of______________, 20____.
________________________(SEAL)
I hereby state that theprincipal, _______________, being of sound mind, signed (or directed another tosign on the principal's behalf) the foregoing health care power of attorney inmy presence, and that I am not related to the principal by blood or marriage,and I would not be entitled to any portion of the estate of the principal underany existing will or codicil of the principal or as an heir under the IntestateSuccession Act, if the principal died on this date without a will. I also statethat I am not the principal's attending physician, nor a licensed health careprovider or mental health treatment provider who is (1) an employee of theprincipal's attending physician or mental health treatment provider, (2) anemployee of the health facility in which the principal is a patient, or (3) anemployee of a nursing home or any adult care home where the principal resides.I further state that I do not have any claim against the principal or theestate of the principal.
(b) Use of thestatutory form prescribed in this section is an optional and nonexclusivemethod for creating a health care power of attorney and does not affect the useof other forms of health care powers of attorney, including previous statutoryforms. (1991, c.639, s. 1; 1993, c. 523, s. 3; 1998‑198, s. 1; 1998‑217, s. 53;2005‑351, s. 3; 2006‑226, s. 32; 2007‑502, s. 6(b); 2008‑187,s. 37(a).)
§ 32A‑25.1. Statutoryform health care power of attorney.
(a) The use of thefollowing form in the creation of a health care power of attorney is lawfuland, when used, it shall meet the requirements of and be construed inaccordance with the provisions of this Article:
HEALTH CARE POWER OF ATTORNEY
NOTE: YOU SHOULD USE THISDOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE AGENT IF YOU ARE COMFORTABLEGIVING THAT PERSON BROAD AND SWEEPING POWERS TO MAKE HEALTH CARE DECISIONS FORYOU. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A HEALTH CARE POWER OFATTORNEY.
EXPLANATION: You havethe right to name someone to make health care decisions for you when you cannotmake or communicate those decisions. This form may be used to create a healthcare power of attorney, and meets the requirements of North Carolina law.However, you are not required to use this form, and North Carolina law allowsthe use of other forms that meet certain requirements. If you prepare your ownhealth care power of attorney, you should be very careful to make sure it isconsistent with North Carolina law.
Thisdocument gives the person you designate as your health care agent broadpowers to make health care decisions for you when you cannot make thedecision yourself or cannot communicate your decision to other people. Youshould discuss your wishes concerning life‑prolonging measures, mentalhealth treatment, and other health care decisions with your health care agent.Except to the extent that you express specific limitations or restrictions inthis form, your health care agent may make any health care decision you couldmake yourself.
Thisform does not impose a duty on your health care agent to exercise grantedpowers, but when a power is exercised, your health care agent will be obligatedto use due care to act in your best interests and in accordance with thisdocument.
ThisHealth Care Power of Attorney form is intended to be valid in any jurisdictionin which it is presented, but places outside North Carolina may impose requirementsthat this form does not meet.
Ifyou want to use this form, you must complete it, sign it, and have yoursignature witnessedby twoqualified witnessesand proved by a notary public. Follow theinstructions about which choices you can initial very carefully. Do not signthis form until two witnesses and a notary public are present to watch yousign it. You then should give a copy to your health care agent and to anyalternates you name. You should consider filing it with the Advance Health CareDirective Registry maintained by the North Carolina Secretary of State: https://www.nclifelinks.org/ahcdr/
1. Designation of HealthCare Agent.
I, __________________, being ofsound mind, hereby appoint the following person(s) to serve as my health careagent(s) to act for me and in my name (in any way I could act in person) tomake health care decisions for me as authorized in this document. My designatedhealth care agent(s) shall serve alone, in the order named.
A. Name: _______________________ HomeTelephone: _______________
Home Address: _______________________ WorkTelephone: _______________
Any successor health care agentdesignated shall be vested with the same power and duties as if originallynamed as my health care agent, and shall serve any time his or her predecessoris not reasonably available or is unwilling or unable to serve in thatcapacity.
2. Effectiveness ofAppointment.
My designation of a health careagent expires only when I revoke it. Absent revocation, the authority grantedin this document shall become effective when and if one of the physician(s)listed below determines that I lack capacity to make or communicate decisionsrelating to my health care, and will continue in effect during that incapacity,or until my death, except if I authorize my health care agent to exercise myrights with respect to anatomical gifts, autopsy, or disposition of my remains,this authority will continue after my death to the extent necessary to exercisethat authority.
1. _______________________ (Physician)
2. _______________________ (Physician)
If I have not designated aphysician, or no physician(s) named above is reasonably available, thedetermination that I lack capacity to make or communicate decisions relating tomy health care shall be made by my attending physician.
3. Revocation.
Any time while I am competent, Imay revoke this power of attorney in a writing I sign or by communicating myintent to revoke, in any clear and consistent manner, to my health care agentor my health care provider.
4. General Statement ofAuthority Granted.
Subject to any restrictions setforth in Section 5 below, I grant to my health care agent full power andauthority to make and carry out all health care decisions for me. Thesedecisions include, but are not limited to:
A. Requesting,reviewing, and receiving any information, verbal or written, regarding myphysical or mental health, including, but not limited to, medical and hospitalrecords, and to consent to the disclosure of this information.
B. Employing ordischarging my health care providers.
C. Consenting to andauthorizing my admission to and discharge from a hospital, nursing orconvalescent home, hospice, long‑term care facility, or other health carefacility.
D. Consenting to andauthorizing my admission to and retention in a facility for the care ortreatment of mental illness.
E. Consenting to andauthorizing the administration of medications for mental health treatment andelectroconvulsive treatment (ECT) commonly referred to as "shocktreatment."
F. Giving consent for,withdrawing consent for, or withholding consent for, X‑ray, anesthesia,medication, surgery, and all other diagnostic and treatment procedures orderedby or under the authorization of a licensed physician, dentist, podiatrist, orother health care provider. This authorization specifically includes the powerto consent to measures for relief of pain.
G. Authorizing thewithholding or withdrawal of life‑prolonging measures.
H. Providing my medicalinformation at the request of any individual acting as my attorney‑in‑factunder a durable power of attorney or as a Trustee or successor Trustee underany Trust Agreement of which I am a Grantor or Trustee, or at the request ofany other individual whom my health care agent believes should have suchinformation. I desire that such information be provided whenever it wouldexpedite the prompt and proper handling of my affairs or the affairs of anyperson or entity for which I have some responsibility. In addition, I authorizemy health care agent to take any and all legal steps necessary to ensurecompliance with my instructions providing access to my protected healthinformation. Such steps shall include resorting to any and all legal proceduresin and out of courts as may be necessary to enforce my rights under the law andshall include attempting to recover attorneys' fees against anyone who does notcomply with this health care power of attorney.
I. To the extent Ihave not already made valid and enforceable arrangements during my lifetimethat have not been revoked, exercising any right I may have to authorize anautopsy or direct the disposition of my remains.
J. Taking any lawfulactions that may be necessary to carry out these decisions, including, but notlimited to: (i) signing, executing, delivering, and acknowledging anyagreement, release, authorization, or other document that may be necessary,desirable, convenient, or proper in order to exercise and carry out any ofthese powers; (ii) granting releases of liability to medical providers orothers; and (iii) incurring reasonable costs on my behalf related to exercisingthese powers, provided that this health care power of attorney shall not givemy health care agent general authority over my property or financial affairs.
5. Special Provisions andLimitations.
(Notice: The authority grantedin this document is intended to be as broad as possible so that your healthcare agent will have authority to make any decisions you could make to obtainor terminate any type of health care treatment or service. If you wish to limitthe scope of your health care agent's powers, you may do so in this section. Ifnone of the following are initialed, there will be no special limitations onyour agent's authority.)
A. Limitationsabout Artificial Nutrition or Hydration: In exercising the authority to makehealth care decisions on my behalf, my health care agent:
______________ shallNOT have the authority to withhold artificial nutrition (Initial) (such as through tubes) OR mayexercise that authority only in accordance with the followingspecial provisions:
______________ shallNOT have the authority to withhold artificial hydration (Initial) (such as through tubes) OR mayexercise that authority only in accordance with the followingspecial provisions:
NOTE: If you initial either block but do not insert any special provisions, yourhealth care agent shall have NO AUTHORITY to withhold artificial nutrition orhydration.
______________ B. LimitationsConcerning Health Care Decisions. In exercising (Initial) the authority to make healthcare decisions on my behalf, the authority of my health care agentis subject to the following special provisions: (Here you mayinclude any specific provisions you deem appropriatesuch as: your own definition of when life‑prolonging measuresshould be withheld or discontinued, or instructions torefuse any specific types of treatment that are inconsistentwith your religious beliefs, or are unacceptable to you for anyother reason.)
NOTE: DO NOT initial unless you insert a limitation.
______________ C. LimitationsConcerning Mental Health Decisions. In (Initial) exercising the authority tomake mental health decisions on my behalf, the authority of myhealth care agent is subject to the following special provisions:(Here you may include any specific provisions you deemappropriate such as: limiting the grant of authority to makeonly mental health treatment decisions, your own instructionsregarding the administration or withholding of psychotropicmedications and electroconvulsive treatment (ECT),instructions regarding your admission to and retention ina health care facility for mental health treatment, orinstructions to refuse any specific types of treatment that areunacceptable to you.)
NOTE: DO NOT initial unless you insert a limitation.
______________ D. AdvanceInstruction for Mental Health Treatment. (Notice: (Initial) This health care power ofattorney may incorporate or be combined with an advanceinstruction for mental health treatment, executed in accordancewith Part 2 of Article 3 of Chapter 122C of the GeneralStatutes, which you may use to state your instructions regardingmental health treatment in the event you lack capacity tomake or communicate mental health treatment decisions. Becauseyour health care agent's decisions must be consistent withany statements you have expressed in an advanceinstruction, you should indicate here whether you have executed anadvance instruction for mental health treatment):
NOTE: DO NOT initial unless you insert a limitation.
______________ E. Autopsyand Disposition of Remains. In exercising the (Initial) authority to make decisionsregarding autopsy and disposition of remains on my behalf, theauthority of my health care agent is subject to the followingspecial provisions and limitations. (Here you may include any specificlimitations you deem appropriate such as: limiting thegrant of authority and the scope of authority, orinstructions regarding burial or cremation):
NOTE: DO NOT initial unless you insert a limitation.
6. Organ Donation.
To the extent I have not alreadymade valid and enforceable arrangements during my lifetime that have not beenrevoked, my health care agent may exercise any right I may have to:
______________ donateany needed organs or parts; or
(Initial)
______________ donateonly the following organs or parts:
______________ donatemy body for anatomical study if needed.
(Initial)
______________ Inexercising the authority to make donations, my health care (Initial) agent is subject to thefollowing special provisions and limitations: (Here you may includeany specific limitations you deem appropriate such as:limiting the grant of authority and the scope of authority, orinstructions regarding gifts of the body or body parts.)
NOTE: DO NOT initial unless you insert a limitation.
NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN THIS INSTRUMENT WITHOUT YOURINITIALS.
7. Guardianship Provision.
If it becomes necessary for acourt to appoint a guardian of my person, I nominate the persons designated inSection 1, in the order named, to be the guardian of my person, to servewithout bond or security. The guardian shall act consistently withG.S. 35A‑1201(a)(5).
8. Reliance of ThirdParties on Health Care Agent.
A. No person who reliesin good faith upon the authority of or any representations by my health careagent shall be liable to me, my estate, my heirs, successors, assigns, orpersonal representatives, for actions or omissions in reliance on thatauthority or those representations.
B. The powers conferredon my health care agent by this document may be exercised by my health careagent alone, and my health care agent's signature or action taken under theauthority granted in this document may be accepted by persons as fullyauthorized by me and with the same force and effect as if I were personallypresent, competent, and acting on my own behalf. All acts performed in goodfaith by my health care agent pursuant to this power of attorney are done withmy consent and shall have the same validity and effect as if I were present andexercised the powers myself, and shall inure to the benefit of and bind me, myestate, my heirs, successors, assigns, and personal representatives. Theauthority of my health care agent pursuant to this power of attorney shall besuperior to and binding upon my family, relatives, friends, and others.
9.Miscellaneous Provisions.
A. Revocation of PriorPowers of Attorney. I revoke any prior health care power of attorney. Thepreceding sentence is not intended to revoke any general powers of attorney,some of the provisions of which may relate to health care; however, this powerof attorney shall take precedence over any health care provisions in any validgeneral power of attorney I have not revoked.
B. Jurisdiction,Severability, and Durability. This Health Care Power of Attorney is intended tobe valid in any jurisdiction in which it is presented. The powers delegatedunder this power of attorney are severable, so that the invalidity of one ormore powers shall not affect any others. This power of attorney shall not beaffected or revoked by my incapacity or mental incompetence.
C. Health Care Agent NotLiable. My health care agent and my health care agent's estate, heirs,successors, and assigns are hereby released and forever discharged by me, myestate, my heirs, successors, assigns, and personal representatives from allliability and from all claims or demands of all kinds arising out of my healthcare agent's acts or omissions, except for my health care agent's willfulmisconduct or gross negligence.
D. No Civil or CriminalLiability. No act or omission of my health care agent, or of any other person,entity, institution, or facility acting in good faith in reliance on theauthority of my health care agent pursuant to this Health Care Power ofAttorney shall be considered suicide, nor the cause of my death for any civilor criminal purposes, nor shall it be considered unprofessional conduct or aslack of professional competence. Any person, entity, institution, or facilityagainst whom criminal or civil liability is asserted because of conductauthorized by this Health Care Power of Attorney may interpose this document asa defense.
E. Reimbursement. Myhealth care agent shall be entitled to reimbursement for all reasonableexpenses incurred as a result of carrying out any provision of this directive.
By signing here, I indicate thatI am mentally alert and competent, fully informed as to the contents of this document,and understand the full import of this grant of powers to my health care agent.
This the _____ day of______________, 20____.
________________________(SEAL)
I hereby state that theprincipal, _______________, being of sound mind, signed (or directed another tosign on the principal's behalf) the foregoing health care power of attorney inmy presence, and that I am not related to the principal by blood or marriage,and I would not be entitled to any portion of the estate of the principal underany existing will or codicil of the principal or as an heir under the IntestateSuccession Act, if the principal died on this date without a will. I also statethat I am not the principal's attending physician, nor a licensed health careprovider or mental health treatment provider who is (1) an employee of theprincipal's attending physician or mental health treatment provider, (2) anemployee of the health facility in which the principal is a patient, or (3) anemployee of a nursing home or any adult care home where the principal resides.I further state that I do not have any claim against the principal or theestate of the principal.
(b) Use of thestatutory form prescribed in this section is an optional and nonexclusivemethod for creating a health care power of attorney and does not affect the useof other forms of health care powers of attorney, including previous statutoryforms. (1991, c.639, s. 1; 1993, c. 523, s. 3; 1998‑198, s. 1; 1998‑217, s. 53;2005‑351, s. 3; 2006‑226, s. 32; 2007‑502, s. 6(b); 2008‑187,s. 37(a).)
