Health Care Directive Form - Minnesota

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 fo r myse l f. 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 car e 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: _____________________________________________________________________________
________________________________________________________________________________________________________________________________
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