OREGON DURABLE POWER OF ATTORNEY FOR HEALTH CARE
(Advance Directive, Health-Care Representative Appointment & HIPAA Authorization)
[// GUIDANCE: This template is designed for use in the State of Oregon pursuant to ORS 127.505 et seq. and the federal HIPAA Privacy Rule, 45 C.F.R. § 164.508. Customize bracketed items, delete guidance blocks, and confirm current statutory requirements before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Appointment & Grant of Authority
- Express Instructions & End-of-Life Provisions
- Representations & Warranties
- Agent Covenants & Standards of Conduct
- Indemnification & Limitation of Liability
- Revocation, Amendment & Termination
- Dispute Resolution
- Miscellaneous
- Execution Block
1. DOCUMENT HEADER
THIS DURABLE POWER OF ATTORNEY FOR HEALTH CARE (this “Instrument”) is executed as of [EFFECTIVE DATE] (the “Effective Date”), by [FULL LEGAL NAME OF PRINCIPAL], residing at [ADDRESS] (the “Principal”), in favor of the Health-Care Representative(s) identified herein (each an “Agent”) under the laws of the State of Oregon.
WHEREAS, ORS 127.505 et seq. authorizes an individual to appoint an Agent to make health-care decisions when the individual lacks capacity; and
WHEREAS, the Principal desires to ensure such decisions reflect the Principal’s values, wishes, and best interests;
NOW, THEREFORE, the Principal hereby states as follows:
2. DEFINITIONS
For purposes of this Instrument, capitalized terms have the meanings set forth below.
“Advance Directive” means this Instrument and any written instructions concerning future health-care decisions executed by the Principal under ORS 127.505 et seq.
“Agent” means the individual(s) appointed in Section 3.1 to act as the Principal’s Health-Care Representative pursuant to ORS 127.505 et seq.
“End-of-Life Care” means medical care provided when the Principal is in a terminal condition or permanently unconscious state, including life-sustaining treatment, artificial nutrition and hydration, and comfort-care measures.
“Good Faith” means honesty in fact and the observance of reasonable standards of health-care decision-making consistent with ORS 127.581.
“Health-Care Decision” has the meaning set forth in ORS 127.505(7).
“HIPAA” means the Health Insurance Portability and Accountability Act of 1996, as amended, and its implementing regulations at 45 C.F.R. parts 160 & 164.
“Incapacity” means the inability to make or communicate health-care decisions, as determined pursuant to ORS 127.505(8).
“Primary Physician” means the physician or other licensed provider who has primary responsibility for the Principal’s health care at the relevant time.
3. APPOINTMENT & GRANT OF AUTHORITY
3.1 Appointment of Agent
a. Primary Agent: [NAME OF PRIMARY AGENT], residing at [ADDRESS], phone [PHONE], email [EMAIL].
b. First Alternate Agent: [NAME] (to serve only if the Primary Agent is unavailable, unwilling, or incompetent).
c. Second Alternate Agent: [NAME] (to serve only if the Primary and First Alternate Agents are unavailable, unwilling, or incompetent).
3.2 Grant of General Authority
The Principal hereby grants each duly-serving Agent full power and authority to make any and all Health-Care Decisions on the Principal’s behalf that the Principal could make if capable, including but not limited to:
a. Consenting to, refusing, or withdrawing any care, treatment, service, or procedure;
b. Authorizing admission to or discharge from health-care facilities;
c. Hiring or firing health-care providers;
d. Accessing, inspecting, and obtaining copies of protected health information (“PHI”) as permitted under HIPAA;
e. Executing waivers, consents, and releases of liability for providers;
f. Making decisions concerning End-of-Life Care and disposition of the Principal’s remains, including funeral or memorial arrangements;
g. Any other authority reasonably necessary to effectuate the foregoing.
3.3 HIPAA Authorization
Pursuant to 45 C.F.R. § 164.508(c), the Principal authorizes each Agent, and any substitute Agent, to obtain, use, and disclose PHI for all purposes necessary to make informed Health-Care Decisions, effective immediately and surviving the Principal’s death to the extent permitted by law. This authorization shall supersede any prior limitations on the release of the Principal’s PHI.
3.4 Effectiveness
This Instrument is effective upon the Effective Date and shall remain in effect notwithstanding the Principal’s Incapacity, except as revoked or terminated herein.
[// GUIDANCE: If the client prefers springing effectiveness—i.e., only upon Incapacity—replace Section 3.4 with a conditional effectiveness clause.]
4. EXPRESS INSTRUCTIONS & END-OF-LIFE PROVISIONS
4.1 Life-Sustaining Treatment
a. [ ] I direct my Agent to request all life-sustaining measures deemed medically appropriate.
b. [ ] I direct my Agent to request only those life-sustaining measures that offer a reasonable hope of recovery to an acceptable quality of life.
c. [ ] I direct my Agent to withhold or withdraw life-sustaining measures if I am in a terminal or permanently unconscious condition.
[// GUIDANCE: Check one box or insert tailored instructions.]
4.2 Artificial Nutrition & Hydration
a. [ ] Provide indefinitely
b. [ ] Trial period of [DAYS/WEEKS]
c. [ ] Withhold/withdraw under circumstances described in 4.1(c)
4.3 Pain Management / Comfort Care
The Agent shall prioritize relief from pain or discomfort, even if such measures may hasten death.
4.4 Organ & Tissue Donation
[ ] I elect to donate any needed organs/tissues for transplantation, therapy, research, or education.
[ ] I do not wish to donate.
[ ] Limited gift: ________.
4.5 Religious & Moral Considerations
The Agent shall honor the following religious or moral directives: ________.
5. REPRESENTATIONS & WARRANTIES
5.1 Principal’s Capacity
The Principal represents that, as of the Effective Date, the Principal is of sound mind and acting voluntarily.
5.2 Agent Eligibility
Each Agent represents, by signing the acceptance below, that the Agent:
a. Is at least 18 years old;
b. Is not the Principal’s attending health-care provider or an employee thereof unless related to the Principal by blood, marriage, or adoption; and
c. Is willing and able to serve.
5.3 Survival
The representations and warranties in this Section survive the Principal’s Incapacity.
6. AGENT COVENANTS & STANDARDS OF CONDUCT
6.1 Good-Faith Standard
The Agent shall act in Good Faith, consistent with the Principal’s expressed wishes and best interests.
6.2 Consultation & Information
The Agent shall consult with the Principal’s Primary Physician and other relevant providers and may, but need not, seek advice from family, clergy, or ethics committees.
6.3 Recordkeeping
The Agent shall maintain reasonable records of material Health-Care Decisions.
6.4 Delegation
The Agent may delegate ministerial tasks but shall not delegate decision-making authority.
7. INDEMNIFICATION & LIMITATION OF LIABILITY
7.1 Indemnification
The Principal and the Principal’s estate shall indemnify and hold harmless any Agent from and against any liability, cost, or expense (including reasonable attorneys’ fees) incurred as a result of actions taken in Good Faith under this Instrument.
7.2 Liability Cap
No Agent shall be liable to the Principal, the Principal’s estate, or any third party for monetary damages except to the extent arising from the Agent’s willful misconduct or gross negligence.
8. REVOCATION, AMENDMENT & TERMINATION
8.1 Revocation by Principal
The Principal may revoke this Instrument in whole or in part at any time by executing a subsequent advance directive or by personally informing the Agent or attending provider of the revocation.
8.2 Automatic Termination
This Instrument terminates upon the earliest of:
a. The Principal’s death (except with respect to Section 3.3, which survives as allowed by law);
b. Court appointment of a guardian with health-care powers unless the court orders otherwise;
c. Dissolution or annulment of marriage between the Principal and a spouse-Agent, unless otherwise specified here: [ ☐ Do NOT revoke spouse-Agent's authority upon divorce ].
8.3 Partial Invalidity
Revocation of any provision shall not affect the validity of the remainder.
9. DISPUTE RESOLUTION
9.1 Governing Law
This Instrument shall be governed by and construed in accordance with the laws of the State of Oregon (“state_healthcare_law”).
9.2 Forum Selection
Exclusive jurisdiction for any proceeding arising under this Instrument shall lie with the [COUNTY] Probate Court (“state_probate_court”).
9.3 Injunctive Relief
Any party with standing may petition the probate court for injunctive or declaratory relief to enforce this healthcare directive.
9.4 Arbitration & Jury Trial
Arbitration is not available, and the parties do not waive any constitutional right to jury trial.
10. MISCELLANEOUS
10.1 Copies Equivalent to Originals
A photocopy, facsimile, or electronically signed counterpart of this Instrument has the same force and effect as an original.
10.2 Severability
If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force.
10.3 Integration
This Instrument constitutes the entire advance directive of the Principal and supersedes all prior inconsistent directives.
10.4 Amendment
Any amendment must be executed with the same formalities as this Instrument.
10.5 Electronic Signatures
To the extent permitted by ORS 84.001 et seq., electronic signatures and counterparts are effective.
11. EXECUTION BLOCK
A. Principal’s Signature
I, [FULL LEGAL NAME], declare under penalty of perjury that I am the person identified herein, that I have read this Instrument, and that the statements within are true and correct.
______ ______
Principal Signature Date
B. Witnesses OR Notary (choose one method)
[// GUIDANCE: Oregon permits either two adult witnesses OR a notary public.]
Method 1 – Witnesses
1. ____ ____
Witness #1 Signature Date
Print Name: ___ Address: _____
-
Witness #2 Signature Date
Print Name: ___ Address: _____
Method 2 – Notary Acknowledgment
STATE OF OREGON )
) ss.
COUNTY OF ______ )
On this _ day of _, 20__, before me, ___, a Notary Public in and for said State, personally appeared ___, known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this Instrument, and acknowledged that he/she executed the same.
Notary Public for Oregon
My Commission Expires: _______
C. Agent Acceptance
I, the undersigned, accept the appointment as Agent and agree to act in Good Faith in accordance with this Instrument and Oregon law.
Primary Agent: ___ Date: _
Alternate #1: ____ Date: _
Alternate #2: ____ Date: _
[// GUIDANCE: Review ORS 127.505 et seq. for any recent legislative changes, confirm witness qualifications, and ensure HIPAA language satisfies 45 C.F.R. § 164.508(c)(1)-(4). Retain completed originals with important records, and provide copies to Agents and health-care providers.]