Healthcare Power of Attorney - Alaska

HEALTH CARE POWER OF ATTORNEY — ALASKA

I, [PRINCIPAL LEGAL NAME], of [ADDRESS], make this durable power of attorney for health care under AS 13.52.010. I appoint the person named below to make health care decisions for me within the limits of this document and Alaska law.

1. Agent and alternates

Primary agent: [FULL NAME]

Address: [________________________________]

Telephone: [________________] Other contact: [________________]

If my primary agent is unwilling, unable, or not reasonably available, I appoint these alternates in order:

1. First alternate: [NAME, ADDRESS, TELEPHONE]
2. Second alternate: [NAME, ADDRESS, TELEPHONE]

I understand that, unless related to me by blood, marriage, or adoption, an agent may not be an owner, operator, or employee of the health care institution at which I am receiving care. I have checked my selections against that restriction.

2. When my agent may act

☐ Upon loss of capacity: My agent's decision-making authority begins when my lack of capacity is determined under AS 13.52.010(g) and ends when my recovery of capacity is determined under that section.

☐ Immediately: My agent's decision-making authority begins when I sign this document. I retain my own decision-making authority while I have capacity.

3. Agent's authority and instructions

My agent may make the health care decisions I could make while having capacity, subject to my instructions below and applicable law. My agent must follow my instructions and other wishes known to the agent. If my wishes are unknown, my agent must decide according to my best interest, considering my personal values to the extent known.

Limits or additional instructions: [________________________________]

Instructions concerning treatment, including artificial nutrition and hydration, if any: [________________________________]

Pain relief and comfort care preferences, if any: [________________________________]

Exceptional procedures: AS 13.52.050 limits an agent's authority to consent to abortion, sterilization, psychosurgery, or removal of bodily organs unless this document or another writing clearly expresses my contrary intent or the statutory life or serious-health exception applies. My specific instructions, if any, are: [________________________________]

Pregnancy: Decisions to withhold or withdraw life-sustaining procedures remain subject to AS 13.52.055. My additional wishes, if any, are: [________________________________]

This power of attorney does not itself issue a do-not-resuscitate order or make an anatomical gift. I will address either matter through the applicable separate process if I wish.

4. Health care information

I do not limit my agent's rights under AS 13.52.070 to request, receive, examine, copy, and consent to disclosure of my health care information while authorized to decide for me. If my capacity is in question, my agent may access the information needed to determine it as that section permits. Any additional information limits are: [________________________________]

5. Guardian nomination

If a guardian of my person is needed, I nominate my primary agent, then my available alternates in the order listed above, for the court's consideration.

6. Revocation and copies

I understand that, outside the special mental-illness rule in AS 13.52.020(c), I may revoke my agent's designation by a signed writing or by personally informing my supervising health care provider. Other instructions may be revoked as AS 13.52.020 permits. A copy of this signed directive has the same effect as the original under AS 13.52.110.

7. Principal's signature

I sign this document voluntarily on [__/__/____].

Principal's signature: [________________________________]

Printed name: [________________________________]

Address: [________________________________]

8. Execution — choose one method

Method A: Two qualified witnesses

Each witness must be personally known to me and must witness my signature or my acknowledgment of it. Neither witness may be my agent, a health care provider employed at the institution or facility where I am receiving care, an employee of my treating provider, or an employee of the institution or facility where I am receiving care. At least one witness must also be neither related to me by blood, marriage, or adoption nor entitled to part of my estate under an existing will, codicil, or law.

We witnessed the principal sign or acknowledge the signature above.

Witness 1 (unrelated and not an estate beneficiary):

Signature: [________________________________] Date: [__/__/____]

Printed name and address: [________________________________]

Witness 2:

Signature: [________________________________] Date: [__/__/____]

Printed name and address: [________________________________]

Method B: Alaska notary acknowledgment

State of Alaska, [________________] Judicial District

On [__/__/____], before me, [NOTARY NAME], appeared [PRINCIPAL NAME], personally known to me or identified by satisfactory evidence, and acknowledged executing this instrument.

Notary signature: [________________________________]

Commission expiration: [__/__/____]

Seal: [AFFIX SEAL]

This template is provided for informational purposes only and does not constitute legal advice. An Alaska attorney should review and customize it before signing.