WISH 1
The Person I Want To Make Health Care Decisions For Me
When I Can’t Make Them For Myself.
f I am no longer able to make my own health care
• My attending or treating doctor finds I am no
I decisions, this form names the person I choose to
longer able to make health ca
es, AND
re choic
E
make these choices for me. This person will be my
• Another health care profe
ssional agrees
t
hat
Health Care Agent (or other term that may be used in
this is true.
MPLE
my state, such as proxy, representative, or surrogate).
If my state has a different
w
ay of finding that I am not
This person will make my health care choices if both
able to make health c
are choices, then my state’s way
of these things happen:
should be followe
d.
The Person I Choose As My Health Care Agent Is:
First Choice Name
Ph
one
Address
City/State/Zip
If this person is not able or willing to make thesee choices for me, OR is divorced or legally separated from me, OR this person has died, then these people aree my next choices:
Second Choice Name
e
Third Choice Nam
Address
A
ddress
City/State/Zip
City/State/Zip
Phone
Phone
Picking The R
Your Health Care Agent
ight Person To Be
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can make difficult
Agent should be at least 18 years or older (in
cares about you, and who
ily member may
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decisions. A spouse or fam
not be the best choice because they are too
•
Your health care provider, including the
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owner or operator of a health or residential
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or community care facility serving you.
w
ho is able to stand up for you so that your
wishes are followed. Also, choose someone who
•
An employee or spouse of an employee of
is likely to be nearby so that they can help when
your health care provider.
you need them. Whether you choose a spouse,
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Agent, make sure you talk about these wishes
more people unless he or she is your
and be sure that this person agrees to respect
spouse or close relative.
