DURABLE POWER OF ATTORNEY FOR HEALTH CARE
(State of Ohio)
[// GUIDANCE: This template is designed to comply with Ohio Rev. Code Ann. §§ 1337.11–1337.17 and applicable federal privacy regulations (45 C.F.R. Parts 160 & 164). Customize bracketed items, delete inapplicable options, and review witness/notary blocks for the execution method selected.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Appointment of Agent
3.2 Effective Date & Durability
3.3 General Grant of Authority
3.4 Specific Health-Care Authorities
3.5 End-of-Life Directives
3.6 HIPAA Authorization
3.7 Nomination of Guardian
3.8 Limitations on Agent Authority
3.9 Reliance & Third-Party Protection - Representations & Warranties
- Covenants & Ongoing Duties
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title and Parties
This Durable Power of Attorney for Health Care (“Power of Attorney”) is executed on [EFFECTIVE DATE] (“Effective Date”) by [FULL LEGAL NAME OF PRINCIPAL], residing at [ADDRESS] (“Principal”), in favor of the individual(s) designated herein as health-care agent(s) (each, an “Agent”).
1.2 Recitals
A. Principal desires to ensure that health-care decisions can be made on Principal’s behalf in accordance with Principal’s wishes should Principal lack decision-making capacity.
B. This Power of Attorney is intended to be valid under Ohio law, including Ohio Rev. Code Ann. §§ 1337.11 et seq., and under the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. § 1320d et seq.
C. Consideration is deemed adequate and acknowledged by the parties.
2. DEFINITIONS
“Advance Directive” – A written statement relating to the provision of health care when the Principal is incapacitated, including this Power of Attorney and any Living Will.
“Agent” – The person authorized herein to make health-care decisions for the Principal.
“Alternate Agent” – A successor Agent designated to act if the primary Agent is unable, unwilling, or legally disqualified to serve.
“Good Faith” – Honesty in fact and the observance of reasonable standards of health-care decision making under the circumstances.
“Health-Care Decision” – Any consent, refusal, or withdrawal of consent to health-care, treatment, service, or diagnostic procedure, including admission to or discharge from a health-care facility.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996 and its implementing regulations at 45 C.F.R. Parts 160 & 164.
[// GUIDANCE: Add additional defined terms if specialized medical or religious provisions are included.]
3. OPERATIVE PROVISIONS
3.1 Appointment of Agent
3.1.1 Principal hereby appoints [NAME OF PRIMARY AGENT], residing at [ADDRESS], as Agent.
3.1.2 Alternate Agents (in the listed order of priority):
(a) [NAME OF FIRST ALTERNATE AGENT];
(b) [NAME OF SECOND ALTERNATE AGENT].
3.2 Effective Date & Durability
3.2.1 This Power of Attorney is [select one]:
☐ Effective immediately upon execution; or
☐ Springing—effective only upon a determination of incapacity by [ONE/TWO] licensed physician(s).
3.2.2 Durability. The authority granted herein shall not be affected by the Principal’s subsequent incapacity or disability.
3.3 General Grant of Authority
Subject to the limitations stated herein, the Agent may make any and all Health-Care Decisions the Principal could make if able, including but not limited to granting or withholding informed consent, arranging transfer between facilities, and accessing medical records.
3.4 Specific Health-Care Authorities
(a) Life-Prolonging Treatment: Authority to consent to, refuse, or withdraw life-sustaining treatment.
(b) Artificial Nutrition & Hydration: Authority to consent to or refuse artificial nutrition or hydration.
(c) Pain Management & Palliative Care.
(d) Organ & Tissue Donation pursuant to Ohio Rev. Code Ann. Chapter 2108.
(e) Autopsy & Disposition of Remains.
(f) Mental Health Treatment, including psychotropic medication and admission to a psychiatric facility not exceeding [30] days per admission.
3.5 End-of-Life Directives
3.5.1 Principal’s Preferences. The Principal expresses the following wishes, which are directive and binding on the Agent, subject to reasonable medical standards:
☐ If I am permanently unconscious or terminally ill and death is imminent, I [DESIRE / DO NOT DESIRE] life-sustaining treatment.
☐ I [DESIRE / DO NOT DESIRE] artificial nutrition and hydration in the foregoing circumstances.
☐ Additional instructions: [__________].
3.6 HIPAA Authorization
The Agent (and any Alternate Agent while acting) is a “personal representative” under HIPAA and is authorized to receive, use, and disclose Protected Health Information (“PHI”) to the extent necessary to carry out the purposes of this Power of Attorney. This authorization is intended to meet the requirements of 45 C.F.R. § 164.502(g) and shall remain effective until revoked per § 3.7.
3.7 Nomination of Guardian
If a court of competent jurisdiction deems a guardian necessary, Principal nominates the Agent (or highest-ranking Alternate Agent then serving) as guardian of the person. No bond shall be required of any guardian so nominated.
3.8 Limitations on Agent Authority
(a) The Agent may not authorize voluntary in-patient admission to a State-operated mental health institution for more than 30 days without court order.
(b) The Agent may not consent to experimental treatment without express written authority herein: [☐ AUTHORIZED / ☐ NOT AUTHORIZED].
(c) The Agent shall act in Good Faith and in accordance with Principal’s known wishes; where unknown, decisions shall be based on Principal’s best interests.
3.9 Reliance & Third-Party Protection
Any health-care provider or third party may rely upon the validity of this Power of Attorney and the instructions of the Agent acting in Good Faith, absent actual knowledge of revocation or termination.
4. REPRESENTATIONS & WARRANTIES
4.1 Principal represents that:
(a) Principal is at least 18 years of age and of sound mind;
(b) No prior instrument conflicts with this Power of Attorney or, if any exist, they are hereby revoked.
4.2 Agent represents, by signing the Acceptance in § 10, that the Agent:
(a) Is willing to serve;
(b) Will act in Good Faith and pursuant to Ohio law; and
(c) Will maintain the confidentiality of PHI except as permitted herein.
5. COVENANTS & ONGOING DUTIES
5.1 Agent shall consult with health-care professionals and family members as practicable.
5.2 Agent shall keep reasonably contemporaneous records of material decisions.
5.3 Principal shall promptly notify health-care providers of any revocation.
6. DEFAULT & REMEDIES
6.1 Events of Default. “Default” means (i) Agent’s breach of Good Faith; (ii) incapacity of Agent; or (iii) resignation without proper notice.
6.2 Notice & Cure. Any interested person may give written notice to the Agent alleging Default. The Agent shall have 48 hours to cure or respond before the Alternate Agent’s authority activates.
6.3 Remedies. Upon Default, any interested person may petition the appropriate county probate court for injunctive relief, removal of Agent, or appointment of a guardian.
7. RISK ALLOCATION
7.1 Indemnification of Agent. The Principal agrees to indemnify and hold the Agent harmless from any liability arising from actions taken in Good Faith pursuant to this Power of Attorney (“agent_good_faith” standard).
7.2 Limitation of Liability. The Agent shall not be liable for any damages except those proximately caused by acts or omissions in bad faith, willful misconduct, or gross negligence (“good_faith_standard” cap).
7.3 Insurance. [OPTIONAL] Principal shall maintain health-care or liability insurance that names the Agent as an additional insured with respect to decisions made hereunder.
8. DISPUTE RESOLUTION
8.1 Governing Law. This Power of Attorney shall be governed by and construed in accordance with the laws of the State of Ohio (“state_healthcare_law”).
8.2 Forum Selection. Exclusive jurisdiction and venue shall lie with the [NAME OF COUNTY] County Probate Court (“state_probate_court”).
8.3 Arbitration. Not available.
8.4 Jury Waiver. Not available.
8.5 Injunctive Relief. Nothing herein limits a party’s right to seek injunctive or declaratory relief to enforce health-care directives (“healthcare_directive”).
9. GENERAL PROVISIONS
9.1 Amendment & Revocation. Principal may amend or revoke this Power of Attorney at any time by (i) a signed, dated writing; (ii) physical destruction with intent to revoke; or (iii) execution of a subsequent inconsistent directive.
9.2 Assignment. The authority granted is personal and non-delegable except to an Alternate Agent expressly named herein.
9.3 Severability. If any provision is held invalid, the remaining provisions shall remain in full force and effect.
9.4 Entire Agreement. This document constitutes the entire and exclusive expression of the Principal’s intent regarding health-care decision making.
9.5 Counterparts; Electronic Signatures. This Power of Attorney may be executed in counterparts and by electronic signature, each of which shall be deemed an original.
9.6 Delivery. A photocopy, facsimile, or electronically transmitted copy shall have the same effect as an original.
10. EXECUTION BLOCK
10.1 Signature of Principal
______ Date: _____
[PRINTED NAME OF PRINCIPAL], Principal
10.2 Witness Attestation (select either Witnesses OR Notary)
We declare that the Principal is personally known to us, appeared to be of sound mind, and signed or acknowledged this Power of Attorney in our presence.
-
____ Date: _
Name: [PRINT] Address: _______ -
____ Date: _
Name: [PRINT] Address: _______
[// GUIDANCE: Each witness must be at least 18, not related by blood, marriage, or adoption, not an attending physician, and not the Agent or Alternate Agent.]
10.3 Notarization (OPTIONAL in lieu of witnesses)
State of Ohio )
County of ______) ss:
On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared [NAME OF PRINCIPAL], known to me or satisfactorily proven to be the person whose name appears above, and acknowledged executing the same for the purposes therein contained.
Notary Public: ____
My Commission Expires: _______
10.4 Agent Acceptance
I, the undersigned Agent, have read the foregoing Power of Attorney and hereby accept the appointment and the obligations imposed.
______ Date: _____
[NAME OF AGENT], Agent
[Repeat acceptance block for each Alternate Agent.]
[// GUIDANCE: After execution, distribute copies to (i) Agent and Alternate Agents, (ii) primary care physician, (iii) local hospital, and (iv) trusted family members. Consider registering with the Ohio Advance Directives Registry if available.]