APPOINTMENT OF HEALTH CARE AGENT
I, Linda Anne Fairchild-Comer, of 54 Imperial Dr., Staunton, Virginia, being of sound mind, voluntarily create this Appointment of Health Care Agent.
PRIOR DESIGNATIONS
I revoke any prior Appointment of Health Care Agent.
APPOINTMENT OF HEALTH CARE AGENT
In the event that I have been determined to be incapable of providing informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my agent for health care decisions:
Maressa L Fairchild
700 Rife Rd Unit 8H
Waynesboro, Virginia, 22980
Telephone: (304) 279-8168
Relationship: Daughter
AGENT'S AUTHORITY
My agent is authorized to act for me in all matters relating to my health care. My agent's powers include, but are not limited to:
- Full power to consent, refuse consent, or withdraw consent to all medical, surgical, hospital and related health care treatments and procedures on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my agent by me;
- Full power to make decisions on whether to provide, withhold, or withdraw artificial nutrition and hydration on my behalf, according to my wishes as stated in this document, or as stated in a separate Living Will, Health Care Directive, or other similar type document, or as expressed to my agent by me;
- Full power to review and receive any information regarding my physical or mental health, including medical and hospital records, in accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), and the American Recovery and Reinvestment Act of 2009 ("ARRA");
- Full power to sign any releases in order to obtain this information;
- Full power to sign any documents required to request, withdraw, or refuse treatment or to be released or transferred to another medical facility.
My agent does not have authority to act for me for any other purpose unrelated to my health care. All of my agent's actions under this power during any period when I am unable to make or communicate health care decisions have the same effect on my heirs, devisees and personal representatives as if I were competent and acting for myself.
WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE
The designation of my health care agent will become effective on my inability to make or communicate health care decisions as determined by my attending physician and will remain in effect until my death, or until I regain competence and revoke it.
AGENT'S OBLIGATIONS
My agent will make health care decisions for me in accordance with this document, and in accordance with any instructions I give in a Living Will, Health Care Directive or other such document (either included in this document or as a separate document), and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent will make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent will consider my personal values to the extent known to my agent.
EFFECT OF COPY
A copy of this Appointment of Health Care Agent has the same effect as the original.
SEVERABILITY
If any part or parts of this Appointment of Health Care Agent is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of such part or parts shall not in any way affect the remaining parts, and this document shall be construed as though the invalid or illegal part or parts had never been included herein. But if the intent of this Appointment of Health Care Agent would be defeated by such construction, then it shall not be so construed.
SIGNATURE
This Appointment of Health Care Agent is made after careful reflection, while I am of sound mind. I am fully informed as to all contents of this document and understand the full import of this grant of powers to my agent. I fully understand that by signing this document, I will permit my agent to make health care decisions for me. I understand that my signature on this document gives my agent authority to provide, withhold, or withdraw consent to health care treatments or procedures on my behalf; to apply for public benefits to defray the cost of my health care; and to authorize my admission to or transfer from a health care facility. I further affirm that I am not signing this document as a condition of treatment or admission to a health care facility.
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Signature: |
_________________________ |
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Name: |
Linda Anne Fairchild-Comer |
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Date: |
____________________ |
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Place: |
Staunton, Virginia |
STATEMENT OF WITNESSES
I, the undersigned witness, declare that Linda Anne Fairchild-Comer, the person who signed this document, is personally known to me and appears to be of sound mind and acting of her own free will and under no duress. She signed (or asked another to sign for her) this document in my presence. I further declare that I am at least 18 years of age, I am not entitled to any portion of Linda Anne Fairchild-Comer's estate, not financially responsible for Linda Anne Fairchild-Comer's health care, not named as Linda Anne Fairchild-Comer's health care Agent in this document, and that I am not married to Linda Anne Fairchild-Comer and not related to Linda Anne Fairchild-Comer by blood or adoption.
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First witness ____________________________ _________________________________ ________________________________ ___________________________ |
Second witness ____________________________ _________________________________ ________________________________ ___________________________ |
RECORD OF COPIES
Record of people and institutions to whom I have given a signed copy of this document:
1. ____________________________________ Date: ____________________
2. ____________________________________ Date: ____________________
3. ____________________________________ Date: ____________________
4. ____________________________________ Date: ____________________
5. ____________________________________ Date: ____________________