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Minnesota Health Care Directive Form

The Minnesota Health Care Directive refers to both power of attorney and a living will as a ‘Health Care Directive’ and provides the Principal with a way to choose the medical treatment they receive if they become unable to themselves through illnesses. A Minnesota health care directive also lets the principal select another person called the `Agent` to become a facilitator of the patient`s health care treatment. It becomes invalid should the patient be found to be pregnant. The document is a formal declaration and is legally binding in the state of Minnesota, it is in accordance with the US statutes §§ 145C.01 to .16 and requires 2 witnesses or a notary.

How to Write

Health Care Directive

The principal must enter their name twice at the top of the first page to show they understand the Minnesota Health Care Directive.

 

Appointment Of Health Agent: Part 1

The details of a health agent and alternative health agent must be entered.

  • Name of agent.
  • Relationship of agent to principal.
  • Telephone number of agent.
  • Address of agent.

 

Powers For Health Agent

The principal must specify any powers given to their agent regarding their health care.

  • Specify powers which their agent may not have over their medical health care treatment.
  • Specify any other powers which their agent may have over their medical health care treatment.

 

Health Care Instructions. Part 2

The principal must complete the relevant sections required that apply to their medical health care treatment.

  • 1) Goals for health care.
  • 2) Fears about health care.
  • 3) Spiritual or religious beliefs and traditions.
  • 4) Beliefs regarding when life is considered not worth living.
  • 5) Thoughts regarding how a medical condition may affect family members.
  • 6) IN THE EVENT OF PREGNANCY, thoughts regarding health care treatment when pregnant.

 

Wishes Regarding Health Care

The principal must express their wishes regarding health care situations.

  • Wishes when there is a good chance of recovery but unable to make the decision personally.
  • Wishes if dying and unable to make a decision personally.
  • Wishes when permanently unconscious and unable to make the decision personally.
  • wishes when completely dependent on others and unable to make the decision personally.
  • Wishes regarding pain relief if this process would affect alertness or shorten life.

Other Wishes

  • Choice of doctor.
  • Choice of residence while receiving health care,
  • Wishes regarding death, for example preferred place to end life.
  • Wishes regarding donations from parts of the body after death.
  • Wishes regarding the body after death.
  • Any other specific wishes regarding healthcare and care after death.

 

Making The Document Legal: Part 3

The principals details must be entered.

  • Signature of principal.
  • Date signed.
  • Date of birth.
  • Address.

OR if a person was nominated to complete the form for the principal

  • Signature of principal.
  • Date signed.
  • Date of birth.
  • Address.
  • Signature of person who completed the form.
  • Name of person who completed the form.

 

Notary

The notary`s details must be entered.

  • Date.
  • Name of principal.
  • Date.
  • Signature of notary.

 

Witnesses

The witnesses details must be entered.

  • Date.
  • Principal`s name.
  • Signature of witness.
  • Address of witness.