MINNESOTA STATUTE § 145C HEALTH CARE DIRECTIVE OF _________________________________________________________________________________________________ (Your Name) I, _______________________________________________________________________, understand this document allows me to do ONE OR BOTH of the following: Part I: Name another person (called the health care agent) to make health care decisions for me if I am unable to decide or speak for myself. My health care agent must make health care decisions for me based on the instructions I provide in this document (Part II), if any, the wishes I have made known to him or her, or must act in my best interest if I have not made my health care wishes known . AND/OR Part II: Give health care instructions to guide others making health care decisions for me. If I have named a health care agent, these instructions are to be used by the agent. These instructions may also be used by my health care providers, others assisting with my health care, and my family, in the event I cannot make decisions for myself. Part I: Appointment of Health Agent This is who I want to make health care decisions for me if I am unable to decide or speak for myself (I know I can change my agent or alternate agent at any time and I know I do not have to appoint an agent or an alternate agent). NOTE: If you appoint an agent, you should discuss this health care directive with your agent and give your agent a copy. If you do not wish to appoint an agent, you may leave Part I blank and go to Part II. When I am unable to decide or speak for myself, I trust and appoint ____________________________________________ ___________ to make health care decisions for me. This person is called my health care agent. Relationship of my health care agent to me: __________________________________________________________________________ Telephone number of my health care agent: ___________________________________________________________________________ Address of my health care agent: ________________________________________________________________________________ _______________________________________________________________________________________________________________________________ (Optional) Appointment of Alternate Health Care Agent: If my health care agent is not reasonably available, I trust and appoint __________________________________________to be my health care agent instead. Relationship of alternate health care agent to me: ____________________________________________________________________ Telephone number of my alternate health care agent:_________________________________________________________________ Address of my alternate health care agent: _____________________________________________________________________________ ________________________________________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO DO IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF (I know I can change these choices) My health care agent is automatically given the powers listed below in (A) through (D). My health care agent must follow my health care instructions in this document or any other instructions I have given to my agent. I f I have not given health care instructions, then my agent must act in my best interest. Whenever I am unable to decide or speak for myself, my health care agent has the power to: (A) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care, treatment, service, or procedures. This includes deciding whether to stop or not start health care that is keeping me or might keep me alive, and deciding about intrusive mental health treatment. (B) (C) Choose my health care providers . Choose where I live and receive care and support when those choices relate to my health care needs. Review my medical records and have the same rights that I would have to give my medical records to other people. (D) If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR if I want to LIMIT any power in (A) through (D), I MUST say that here: ___________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ My health care agent is NOT automatically given the powers listed below in (1) and (2). If I WANT my agent to have any of the powers in ( 1) and (2), I must INITIAL the line in front of the power; then my agent WILL HAVE that power . (1) To decide whether to donate any parts of my body, including organs, tissues, and eyes, when I die. To decide what will happen with my body when I die (burial, cremation). (2) If I want to say anything more about my health care agent's powers or limits on the powers, I can say it here: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Part II: Health Care Instructions NOTE: Complete this Part II if you wish to give health care instructions. I f yo u appointed an agent i n Part I, completing this Part II is optional but would be very helpful to your agent. However, if you chose not to appoint an agent in Part I, you MUST complete some or all of this Part 11 if you wish to make a valid health care directive. These are instructions for my health care when I am unable to decide or speak for myself. These instructions must be followed (so long as they address my needs). THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE (I know I can change these choices or leave any of them blank) I want you to know these things about me to help you make decisions about my health care: 1. My goals for my health care:____________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 2. My fears about my health care:__________________________________________________________ ________________________________________________