Living Will Legal Forms and Contracts

The following free living will is a thorough will written for a married man with one child. This will and contract is being provided for example, sample, information and research purposes only, however it is a valid legal contract and agreement. Always consult an Attorney or Lawyer.

This document should be used in conjunction with a Trust, Last Will and Testament, Durable Power of Attorney and Health Care Power of Attorney. All these documents can be found in the Trusts and Estate Section of this website. This Agreement can apply in most states including California, New York, Florida, Nevada and others. Help improve this agreement by leaving a comment.

LIVING WILL

OF
__________________

I, __________________, being a resident of Scottsdale, Maricopa County, Arizona, and an adult of sound and disposing mind and memory, not acting under duress, menace, fraud, or undue influence of any person, do make, publish, and declare this to be my Living Will to be used in the event that I am unconscious or mentally incapacitated and, at the same time, have a catastrophic medical condition.

I. Objective, Purpose, and Intent. I realize that, when I am conscious and functioning normally with full mental facilities, I have a legal right to accept or reject medical treatment offered to me by physicians, hospitals, or other medical instrumentalities. It is my intent with this Living Will to designate surrogates who are legally empowered to act for me when I am unconscious or mentally incapacitated with full authority from me to make medical decisions for me and to accept or reject medical treatment on my behalf. I rely on the common law and desire that this Living Will be enforced even if I am in a state of the United States or in a country of the world which has not adopted specific statutes related to the enforcement of Living Wills.

My objective in executing this Living Will is to allow surrogates appointed by me in this document to give written permission to withdraw medical care and authorize pain-killing drugs for me when two (2) physicians, one of whom shall be my attending physician and my Agent to Make Decisions listed in this document, shall determine that I am in an irreversible coma, persistent vegetative state or brain-dead or damaged to such an extent that there is no reasonable hope for recovery.

II. Guidance as to Life-Sustaining Treatment:

The following declaration is intended to give guidance to my agent concerning the use of life-sustaining treatment (treatment intended to keep me alive, such as feeding tubes, breathing machines, CPR) (initial all that apply):

_________2.1 If I have a terminal condition I do not want my life to be prolonged and I do not want life-sustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death.

_________2.2 If I am in a terminal condition or an irreversible coma or a persistent vegetative state that my doctor’s reasonably feel to be irreversible or incurable, I do want the medical treatment necessary to provide care that would keep me comfortable, but I do not want the following:

_________(a) cardiopulmonary resuscitation, for example, the use of drugs, electric shock and artificial breathing;

_________(b) artificially administered food and fluids;

_________(c) to be taken to a hospital, if all avoidable.
_________2.3 Notwithstanding my other directions I do want the use of all medical care necessary to treat my condition until my doctors and my Agent reasonably conclude that my condition is terminal or is irreversible and incurable or I am in a persistent vegetative state.

_________2.4 I want my life to be prolonged to the greatest extent possible.

III. Artificial Nutrition and Hydration Instructions:

I am initialing the declaration below which best expresses my wishes if I cannot drink or eat ordinary food and water delivered by mouth (Initial which applies):

_________3.1 If my health care agent, in consultation with my physician(s) determines that the withdrawal or withholding of life-sustaining treatment is appropriate, he / she DOES HAVE the authority to direct that artificially provided fluids and nutrition, such as by feeding tube or intravenous infusion, be withheld or withdrawn, or

_________3.2 My health care agent DOES NOT HAVE the authority to direct that artificially provided fluids and nutrition, such as by feeding tube or intravenous infusion, be withheld or withdrawn.

IV. Autopsy and Organ Donation Instructions:

I authorize my health care agent to consent to (Initial choices):

Organ donation __________yes __________no

Autopsy __________yes __________no

V. Comfort Care:

I want the performance of medical procedures necessary to provide me with comfort care.

VI. Effect on Other Advance Directives:

I revoke any prior Living Will made in Arizona, and intend this document to take precedence in Arizona over any Living Will I may have executed in another state.

VII. Revocation of this Document:

This Living Will can be revoked by: (1) written statement; (2) orally, by notifying the health care agent or a health care provider; or (3) by any other specific expression of intention to revoke this document or remove the health care agent.

VIII. Designation of Agent to Make Decision.

I, __________________, appoint the following person as my agent to make decisions regarding my medical treatment:

Name:

Address:

Telephone: (mobile)

IX. Designation of Alternate Agents if Above-Named Agent Cannot Serve. If the person named as my agent is unwilling, or unable to act as my agent, or cannot be reached after reasonable efforts have been made, then I appoint the following persons, in the order of priority set forth, to serve:

Name:

Address:

Telephone: (mobile)

X. New HIPAA Regulations Require Amendment. A recent federal regulation known as the Health Insurance Portability and Accountability Act (HIPAA) regarding disclosure of individually identifiable health information necessitated the addition of a special release and consent authority to all healthcare providers before medical information will be released to the Agent of the patient.

XI. HIPAA Release Authority. I instruct that my agent be treated as I want to be treated with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act, 42 USC 1320d and 45 CFR 160-164.

XII. Legal Consent for Disclosure of Health Care Information. Any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other health care provider, any insurance company, the Medical Information Bureau Inc. or other health care clearinghouse that has provided treatment or services shall give, disclose and release to my designated Agent, without restriction, identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include all information relating to the diagnoses treatment of HIV / AIDS, sexually transmitted diseases, mental illness and drug or alcohol abuse.

XIII. Legal Consent for Disclosure of Specific Mental Health Care Information. Any psychologist, psychiatrist, licensed therapist or other healthcare provider involved with diagnoses or therapy or other treatment of me which pertains to my mental health shall give disclose and release to my designated Agent any and all individually identifiable health information and medical records involving any past present or future mental health condition. This specific authorization includes but is not limited to psychotherapy notes defined by HIPAA as “notes recorded in any medium by a mental health professional documenting or analyzing the contents of conversation during a private counseling session”, as well as medication prescription and monitoring, counseling session sart and stop times, modalities and frequencies of treatment, results of clinical tests, and any summary of diagnosis, functional status, treatment plans, symptoms, prognosis or progress. My Agent shall have the same rights of access to these notes as I am entitled to under the provisions of HIPAA and under applicable state law.

XIV. Supersession of Prior Documents and Expiration Event. The authority given my agent in this legal consent form shall supercede any prior agreements that I may have made with my health care providers to restrict access or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider.

XV. Release and Hold Harmless Provision. In order to induce the disclosing party to disclose the aforesaid private and / protected confidential information, I forever release and hold harmless said disclosing party who relies on this instrument from any liability under confidentiality rules arising from HIPAA as a consequence of said disclosure.

XVI. Signature.

By my signature or mark below I indicate that I understand the purpose and effect of this document.

IN WITNESS WHEREOF, I hereunto set my hand this date.

_________________________________ _________________________________
Date Signed __________________, Declarant

WITNESSES

This Living Will, consisting of 5 pages, including this page and the following page(s), was signed in the presence of us who, at the request and in the presence of Testator and in the presence of each other, have signed the same as witnesses thereto. WE ALSO AFFIRM THAT WE ARE NOT RELATED TO THE TRUSTOR BY BLOOD, MARRIAGE OR ADOPTION AND THAT WE ARE AWARE OF NO INHERITANCE RIGHTS, GIFTS, OR DISTRIBUTIONS THAT WE SHALL RECEIVE FROM TRUSTOR’S WILL OR FROM ANY OTHER SOURCE FROM THE TESTATOR AND ARE NOT PERSONS INVOLVED WITH THE MEDICAL CARE OF THE TESTATOR.

Witness Signature

Witness Name (Printed) Witness Address

Witness Signature

Witness Name (Printed) Witness Address

ACKNOWLEDGMENT AND VERIFICATION
OF DECLARANT AND WITNESSES

STATE OF: __________________
COUNTY OF: __________________

On this _______ day of _________________, ________, this instrument was acknowledged before me, a Notary Public, personally appeared the above witnesses known to me or satisfactorily proven to be the person whose names are subscribed to this instrument and acknowledged that they executed the same for the purposes contained therein.

IN WITNESS WHEREOF, I hereunto set my hand and official seal.

______________________________
Notary Public

Printed Name: _________________

My Commission Expires: ______________________

Commission # __________________