• The Durable Power of Attorney for Health Care (Health Care Agent) allows you to name one or more persons to communicate health care decisions on your behalf if you cannot communicate for yourself. This person(s) is called your Health Care Agent.

    Click here for more information (PDF) on the Advance Care Directive forms.

  • Durable Power of Attorney for Health Care / Health Care Agent

    For more information about this document, see the side-bar to the right. After filling out all the sections below, you must download your completed document and sign it. Contact us if you have any questions. Note: Honoring Choices Idaho does not collect, save, or store completed documents. See the section “What do I do when my documents are complete?” for information on how to share your completed document.

  • Personal Identification

  • My choice for Health Care Agent

  • A Health Care Agent only makes decisions when a person cannot make decisions for him or herself.

    We recommend that you designate at least one alternate.

    Initial at the bottom of the first printed page if you do not wish to designate a Health Care Agent. If you do not want to identify a Health Care Agent, your preferences expressed in the Living Will section of the advance directive will be used to guide care.

  • If I am ill or injured and unable to communicate my health care decisions, or if my health care provider determines I cannot make my own health care decisions, then I choose the person(s) listed below to communicate my health care decisions on my behalf.

  • If my first choice for Health Care Agent is unable, unavailable, or unwilling to communicate these choices for me, then my alternate Health Care Agent is:

  • If this alternate Health Care Agent is unable, unavailable, or unwilling to communicate these choices for me, then my 2nd alternate Health Care Agent is:

  • If applicable, initial when printed____Initial here if you do not wish to name a Health Care Agent and direct your health care providers to use the instructions and decisions written in the document Living Will for Health Care to guide medical decisions.

  • Decisions my Health Care Agent(s) may communicate and direct on my behalf

  • The "Decisions my Health Care Agent(s) may communicate and direct on my behalf" section allows you to provide additional guidance to the Health Care Agent(s). You can list additional provisions or limitations for your Health Care Agent(s).

    This section is specific to Health Care Agent(s)' authority; treatment exceptions/preferences are on the Living Will for Health Care form.

    If you wish to write more information than will fit into the space provided, please do so on a separate document and attach to your Durable Power of Attorney for Health Care.

    To be a valid, legal Durable Power of Attorney for Health Care, you must sign and date the printed page.

  • If I am unable to communicate my health care decisions, my Health Care Agent(s) above have the following authority and responsibilities:

    • Follow the instructions on this directive that are based on my wishes, values and beliefs.
    • Consent for treatment(s) such as tests, medications, surgery, or other treatments.
    • Refuse or stop treatment(s) such as tests, medications, surgery, or other treatments.
    • Release my medical records as needed, as stated by law (HIPAA and the Idaho Health Records Act).
    • Determine which health care provider(s) and organization(s) will best meet my health care needs.
    • Arrange for the care of my body after death if my wishes are not already known.
  • Sign and date when printed I understand that any Durable Power of Attorney/Health Care Agent document created before today is no longer valid.

  • Please note: We will only use your email to send you the filled out document. We will not send any additional correspondence to your email, unless expressly requested. We also will not share your email with any third party.

    If you are ready to print and sign your document to create a legal document, click "COMPLETE & DOWNLOAD/PRINT).

    If you want to continue working on your document, click on "Save and Continue Later" to get link to return and make changes. Your link expires after 7 days, and the information you’ve entered will no longer be saved.
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