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Rhode Island Medical Power of Attorney Form |
Rhode Island Medical Power Of Attorney Form is in accordance with US statutes §23- 4.10-1 to -12. It allows the principal to formally appoint an agent to make health care decisions for them. The agent`s powers can be restricted as well as the specific health care decisions of the principal being noted. The principal may do this by completing the relevant blank fields of the document with respects to which criteria they wish to apply to themselves. The document will then become effective in times when they should become ill and are no longer able themselves.
How to Write
Durable Power Of Attorney
The principal must enter their name and then initial the bottom of each page.
Appointment Of Health Care Agent (Part 1)
The agent`s and alternative agent`s details must be entered.
- Name.
- Telephone number.
- Address.
- Enter any limitations to the agent`s authority regarding the principal`s health care.
Health Care Instructions (Part 2)
The principal must use the corresponding blank fields to enter details of their feelings regarding their medical health care.
- Regarding preservation of life.
- Regarding pain management if it impairs alertness or shortens life.
- Regarding religious beliefs.
- Regarding financial considerations.
- Regarding discussion of these issues with a third party.
The principal must initial the relevant blank field to indicate their instructions regarding their medical health care if close to death where treatment would only prolong dying.
- To receive a feeding tube.
- To not receive a feeding tube.
- To receive applicable life support.
- To not receive applicable life support.
If unconscious and unlikely to regain consciousness.
- To receive a feeding tube.
- To not receive a feeding tube.
- To receive applicable life support.
- To not receive applicable life support.
If suffering from a fatal illness or an end stage condition and totally dependent.
- To receive a feeding tube.
- To not receive a feeding tube.
- To receive applicable life support.
- To not receive applicable life support.
The principal can add any other provisions and limitations they require regarding their medical health care.
Organ Donation
The principal must initial the blank fields if they feel this is relevant to their wishes regarding organ donation.
- To donate for the purposes of transplant.
- To donate for the purposes of research.
Religious And Spiritual Requests
The principal must express whether or not they want a religious or spiritual advisor, and of so enter their details.
- Iniital `Yes` or `No`.
- Name of advisor.
- Address of advisor.
- Telephone number of advisor.
Duration
The principal must state the length of duration of the power of attorney will.
Dates And Signatures
The principal, witnesses and notary must enter their details.
- Principals signature.
- Date.
- Witnesses signature.
- Witnesses name.
- Witnesses address.
- Date.
- Notary`s signature.
- Notary`s name.
- Date of expiration of commission.
- Business address.
- Date.
Public Declaration
The relevant witnesses or notary must enter their details.
- Signature.
- Name.
Distributing The Document (Part 4)
The principal can check the relevant box and enter the details of any person they wish to leave a copy of the power of attorney for health care with.
- Health care agent and alternative health care agents.
- Physician.
- Family.
- Lawyer.
- Any others.
The principal may add any additional information they feel relevant.
