Chapter 455, a partnership thereof, a corporation thereof that provides health care services, an operational cooperative sickness
care plan organized under State Statute 185.981 to 185.985 that directly provides services through salaried employees in its own
facility, or a home health agency, as defined in State Statute 50.49 (1) (a). ‘Incapacity’ means the inability to receive and
evaluate information effectively or to communicate decisions to such an extent that the individual lacks the capacity to manage
his or her health care decisions. ‘Feeding tube’ means a medical tube through which nutrition or hydration is administered into
the vein, stomach, nose, mouth or other body opening of the declarant.
Who may sign a Power of Attorney for Health Care? An individual who is of sound mind and has attained age 18 may
voluntarily execute a Power of Attorney for Health Care. An individual for whom an adjudication of incompetence and
appointment of a guardian of the person is in effect under State Statute Chapter 54 is presumed not to be of sound mind.
Procedure for signing a Power of Attorney for Health Care The principal (person creating the Power of Attorney for Health
Care) and the witnesses all must sign the form at the same time.
When does it take effect? Unless otherwise specified in the Power of Attorney for Health Care instrument (form), an
individual’s Power of Attorney for Health Care takes effect upon a finding of incapacity by 2 physicians, as defined in State
Statute 448.01 (5), or one physician and one licensed psychologist, as defined in State Statute.455.01 (4), who personally
examine the principal and sign a statement specifying that the principal has incapacity. Mere old age, eccentricity, or physical
disability, either singly or together, is insufficient to make a finding of incapacity. Neither of the individuals who make a
finding of incapacity may be a relative of the principal nor have knowledge that he or she is entitled to or has a claim on any
portion of the principal’s estate. A copy of the statement, if made, shall be appended to the Power of Attorney for Health Care
instrument.
Revocation A principal may revoke his or her Power of Attorney for Health Care and invalidate the Power of Attorney for
Health Care instrument at any time by doing any of the following: canceling, defacing, obliterating, burning, tearing or
otherwise destroying the Power of Attorney for Health Care instrument or directing another in the presence of the principal to
so destroy the Power of Attorney for Health Care instrument; executing a statement, in writing, that is signed and dated by the
principal, expressing the principal’s intent to revoke the Power of Attorney for Health Care; verbally expressing the principal’s
intent to revoke the Power of Attorney for Health Care in the presence of 2 witnesses; or, executing a subsequent Power of
Attorney for Health Care instrument. The principal’s health care provider shall, upon notification of revocation of the
principal’s Power of Attorney for Health Care instrument, record in the principal’s medical record the time, date and place of
the revocation and the time, date and place, if different, of the notification to the health care provider of the revocation.
Immunities No health care facility or health care provider may be charged with a crime, held civilly liable, or charged with
unprofessional conduct for any of the following: certifying incapacity under State Statute 155.05 (2), if the certification is made
in good faith based on a thorough examination of the principal; failing to comply with a Power of Attorney for Health Care
instrument or the decision of a health care agent, except that failure of a physician to comply constitutes unprofessional conduct
if the physician refuses or fails to make a good faith attempt to transfer the principal to another physician who will comply;
complying, in the absence of actual knowledge of a revocation, with the terms of a Power of Attorney for Health Care
instrument that is in compliance with Chapter 155; complying with the decision of a health care agent that is made under a
Power of Attorney for Health Care that is in compliance with Chapter 155; acting contrary to or failing to act on a revocation of
a Power of Attorney for Health Care, unless the health care facility or health care provider has actual knowledge of the
revocation; or, failing to obtain the health care decision for a principal from the principal’s health care agent, if the health care
facility or health care provider has made a reasonable attempt to contact the health care agent and obtain the decision but has
been unable to do so. No health care agent may be charged with a crime or held civilly liable for making a decision in good faith
under a Power of Attorney for Health Care instrument that is in compliance with Chapter 155. No health care agent who is not
the spouse of the principal may be held personally liable for any goods or services purchased or contracted for under a Power of
Attorney for Health Care instrument.
General provisions The making of a health care decision on behalf of a principal under the principal’s Power of Attorney for
Health Care instrument does not, for any purpose, constitute suicide. No individual may be required to execute a Power of
Attorney for Health Care as a condition for receipt of health care or admission to a health care facility. No insurer may refuse to
pay for goods or services covered under a principal’s insurance policy solely because the decision to use the goods or services
was made by the principal’s health care agent.
Important:
You must keep pages 1-6 of the form together as your executed document. Copies distributed
to health care providers, etc. must include pages 1 - 6.
Resume Templates 1210 Document(s)
