Washington Durable Power of Attorney for Health Care for

[My Name]

1.	Agent. I choose 	as my Agent with full authority to manage my health care.

2.	Alternate. If 	is unable or unwilling to act, I choose
 	as my Agent with full authority to manage my health care.

3.	My Rights. I keep the right to make health care decisions for myself as long as I am capable.

4.	Durable. My Agent can still use this power of attorney document to manage my affairs even if I become sick or injured and cannot make decisions for myself. This power of attorney shall not be affected by my disability.

5.	Start Date. This power of attorney document is effective on the day I sign it in front of a notary public.

6.	End Date. This power of attorney document will end if I revoke it or when I die. If my spouse or domestic partner is my Agent, this power of attorney document will end if either of us files for divorce in court.

7.	Revocation. I revoke any other power of attorney for health care documents I have signed in the past. I understand that I may revoke this power of attorney document at any time by giving written notice of revocation to my Agent.

8.	Powers. My Agent shall have full power and authority to do anything as fully and effectively as I could do myself, including the power to make health care decisions and give informed consent to my health care, refuse and withdraw consent to my health care, employ and discharge my health care providers, apply for and consent to my admission to a medical, nursing, residential or other similar facility that is not a mental health treatment facility, serve as my personal representative for all purposes under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended, and to visit me at any hospital or other medical facility where I reside or receive treatment

9.	Mental Health Treatment. My Agent is not authorized to arrange for my commitment to or placement in a mental health treatment facility. My Agent is not authorized to consent to electroconvulsive therapy, psychosurgery, or other psychiatric or mental health procedures that restrict physical freedom of movement.

10.	No Power to Agree to Binding Pre-Dispute Arbitration. I recognize that some long-term-care providers will ask me or my Agent to sign a binding pre-dispute arbitration agreement. These agreements limit my right to sue the provider before any injury or dispute occurs. I think these agreements are unfair and unacceptable. Therefore, my agent does not have the power to agree to pre-dispute binding
arbitration or any other process involving my person or property that limits my right to a jury, to sue for money, or to join a class action.

11.	Accounting. My Agent shall keep accurate records of my financial affairs and show these records to me at my request.

12.	Nomination of Guardian. I nominate my Agent as the guardian of my person for consideration by the court if guardianship proceedings become necessary.

13.	HIPAA Release. I authorize my healthcare providers to release all information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to my Agent.

My Signature ___________________________	Date ________________

Witness 1	Witness 2
_______________________	_______________________
Signature	Signature

_______________________	_______________________
Name	Name

_______________________	_______________________
Address	Address

Notarization (Optional)

State of Washington
County of  	

I certify that I know or have satisfactory evidence that 	, is the person who appeared before me, signed above, and acknowledged that the signing was done freely and voluntarily for the purposes mentioned in this instrument.

SUBSCRIBED and SWORN to before me on 	.

SIGNATURE OF NOTARY

PRINT NAME OF NOTARY
NOTARY PUBLIC for the State of Washington.
My commission expires 	.