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Alaska Durable Medical Power of Attorney Form |
The Alaska medical power of attorney form is to formally appoint a person or `Attorney In Fact` to be the nominated decision maker regarding medical health care treatment on the patient`s. This authority would be required if the patient becomes incapacitated to a level where they are no longer coherent or conscious, this could include brain damage or a coma for example. The document requires at least two witnesses or a notary in accordance with AS 13.52.010(b)
How to Write
Step 1 – Download and carefully read all of the document before completing the blank fields, the instructions below detail what is required.
Pages 4 – 5. Part 1. Durable Power Of Attorney For Health CAre Decisions
1) Designation Of Agent
- Print name of agent
- Address
- Telephone numbers Home/Work
- Cell phone & Pager
- Email address
If the principal wishes up to two auxiliary agents may also be nominated. This is in case of an event due to which the primary agent is unable to carry out the agents duties.
OPTIONAL
- Print name of alternative agent #1
- Address
- Telephone numbers Home/Work
- Cell phone & Pager
- Email address
OPTIONAL
- Print name of alternative agent #2
- Address
- Telephone numbers Home/Work
- Cell phone & Pager
- Email address
2) Agent`s Authority
- Option to enter the specific wishes of the principal to be carried out by the agent and giving authority to the agent regarding health care decisions should the principal be unable to do so themselves.
Page 6. Part 2. (6) End of life decisions.
- Initial selection `A`choice to prolong life or `B` choice not to prolong life.
- If selecting section `B` then also initial either `B(i) permanent unconsciousness` or `B(ii)` terminal condition and/or `B(iii)` additional instructions.
- Initial one of the following selections regarding artificial nutrition and hydration `C (i), (ii), (iii), (iv) and/or (v) for other instructions`.
- Agree to the statement provided in section `D` or give instructions regarding relief of pain.
- Give instructions for section `E` regarding consciousness during pregnancy.
(7) Other wishes
Enter details of principals other wishes regarding end of life decisions.
Page 8. Part 3. Anatomical Gift Of Death (OPTIONAL)
(8) Upon Death
- Check Box `A`to give any organs, tissues or other body parts.
- Check box `B` to choose specifically the organs, tissues and other body parts to give. Enter names of these.
- Check Boxes to describe the specific purposes designated for the anatomical gift upon death.
- Check box `C` if an anatomical gift is NOT to be given.
Pages 8 – 9. Part 4. Mental Health Treatment
9) Psychotropic Medications
- Check box to either give consent for the administration of certain medicines, also to be named here by the principal or initial to not consent to the administration of certain medicines to be named here by the principal.
- Enter requirements for any other conditions or limitations regarding the principal`s mental health treatment.
10) Electroconvulsive Treatment
- Check box either to give consent or to not give consent for the use of electroconvulsive treatment.
- Enter requirements for any other conditions or limitations regarding the principal`s electroconvulsive treatment.
11) Admission To Retention
- Initial either to give consent, includuing the number of days consent can be given for (up to 17 days). Alternatively to not give consent for admission to and retention in facility.
- Enter requirements for any other conditions or limitations regarding the principal`s admission to and retention in facility .
Enter any other mental health wishes or instructions, including conditions or limitations.
Page 10. Part 5. Primaery Physician
13) Details of the primary physician to be treating the principal.
- Enter primary physicians name
- Facility/Office
- Address
- Phone
Optional
Details of the secondary physician to be treating the principal. This is in case of an event due to which the primary physician is unable to carry out the physicians duties.
- Enter secondary physicians name
- Facility/Office
- Address
- Phone
14) Signatures
- Enter the principal`s signature
- Print the Principal`s full name
- Date Completed
- Address
15) Witnesses
Alternative #1
Enter the details of first witness who IS NOT a devisee or relation of the principal.
Required
- Signature
- Printed name
- Date
- Residence address and judicial district
Enter the details of the second witness who May be a devisee or relation to the principal.
Required
- Signature
- Printed name
- Date
- Residence address and judicial district
Alternative #2 Certificate Of Notarization
- County/Judicial district
- Place
- Day/Month/Year
- Officer name/Title
- Name of principal
- Signature of notary public or officer
- Date commission expires
- Notary seal
