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Tool #1 How to Select Your Health Care Agent or Proxy Name & Date When you decide to pick someone to speak for you in a medical crisis, in case you are not able to speak for yourself, there are several
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How to fill out your health care agent

How to fill out your health care agent:
01
Start by selecting a trusted individual to serve as your health care agent. This person should be someone who understands your values and preferences regarding medical treatment.
02
Consult with an attorney or use a state-specific health care agent form to ensure that you follow the legal requirements of your jurisdiction.
03
Provide the necessary personal information, such as your full name, date of birth, and contact details.
04
Specify the powers you want to grant to your health care agent. These can include making medical decisions on your behalf, accessing your medical records, and consenting to or refusing certain treatments.
05
Clearly state any limitations or specific instructions you want your health care agent to follow. This can be related to religious or personal beliefs, desired treatment options, end-of-life decisions, or organ donation preferences.
06
Discuss your wishes with your health care agent so they fully understand your expectations and can advocate for your needs in the event you cannot do so yourself.
07
Sign and date the document, and ensure it is witnessed or notarized, as required by your jurisdiction.
08
Provide copies of the completed health care agent form to your health care provider, attorney, designated health care agent, and any other relevant individuals.
Who needs your health care agent?
01
Every adult should consider having a health care agent. Unexpected medical situations can arise at any age, and having someone you trust to make informed decisions on your behalf is crucial.
02
Those with chronic illnesses, terminal conditions, or complex medical histories may particularly benefit from appointing a health care agent to ensure their wishes are respected and their best interests are represented.
03
It is also recommended for individuals who are elderly, vulnerable, or frequently traveling, as they may require assistance with medical decision-making in various circumstances.
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What is your health care agent?
Your health care agent is the person designated to make medical decisions on your behalf if you are unable to do so.
Who is required to file your health care agent?
You are required to file your health care agent by completing a health care proxy form.
How to fill out your health care agent?
You can fill out your health care agent by completing a health care proxy form and ensuring it is signed and dated.
What is the purpose of your health care agent?
The purpose of your health care agent is to ensure that your medical wishes are followed if you become incapacitated.
What information must be reported on your health care agent?
Your health care agent must include the name of your designated agent and any specific medical wishes you have.
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