UTAH HEALTHCARE POWER OF ATTORNEY
(Utah Code Ann. §§ 75-2a-101 et seq.)
[// GUIDANCE: This template is drafted to comply with the Utah Advance Health Care Directive Act. Practitioners should confirm no subsequent statutory amendments have altered execution formalities before finalizing.]
I. DOCUMENT HEADER
Healthcare Power of Attorney & Advance Directive
This Healthcare Power of Attorney (the “Directive”) is executed this [EFFECTIVE DATE] (the “Effective Date”) by [DECLARANT FULL LEGAL NAME], residing at [DECLARANT ADDRESS] (the “Declarant”), pursuant to Utah Code Ann. §§ 75-2a-101 et seq.
II. TABLE OF CONTENTS
- Definitions
- Appointment of Agent & Successor Agent
- Scope of Authority (Operative Provisions)
- End-of-Life Provisions
- HIPAA Authorization
- Representations & Warranties
- Covenants & Restrictions of Agent
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block & Certification
1. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings assigned below:
“Act” – Utah Advance Health Care Directive Act, Utah Code Ann. §§ 75-2a-101 et seq.
“Agent” – The individual appointed in Section 2.1.
“Good Faith” – Honesty in fact and the observance of reasonable standards of healthcare decision-making under the circumstances.
“Health Care” – Any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a person’s physical or mental condition.
“Life-Prolonging Treatment” – Medical interventions customarily used to sustain life when death is otherwise imminent.
“Protected Health Information” or “PHI” – The term defined in 45 C.F.R. § 160.103.
2. APPOINTMENT OF AGENT & SUCCESSOR AGENT
2.1 Primary Agent. The Declarant hereby designates [PRIMARY AGENT NAME], whose address is [PRIMARY AGENT ADDRESS], as his/her true and lawful Agent to make Health Care decisions on the Declarant’s behalf.
2.2 Successor Agent. If the Primary Agent is unable, unwilling, or ineligible to act, the Declarant appoints [SUCCESSOR AGENT NAME] as the successor Agent.
2.3 Eligibility. An Agent shall be at least 18 years of age and not currently serving as the Declarant’s healthcare provider, unless the individual is a family member.
3. SCOPE OF AUTHORITY (OPERATIVE PROVISIONS)
3.1 General Grant. Subject to the limitations herein, the Agent may make any and all Health Care decisions that the Declarant could make if capable, including without limitation:
(a) consent, refuse, or withdraw consent to any Health Care;
(b) select or discharge healthcare facilities and providers;
(c) approve diagnostic tests, surgical procedures, and medication plans;
(d) have access to all medical records and PHI.
3.2 Mental Health Treatment. The Agent’s authority expressly extends to psychiatric and psychological care, including admission to mental health facilities in conformity with the Act.
3.3 Organ & Tissue Donation. [SELECT ONE]:
☐ Yes – Agent may authorize organ/tissue donation pursuant to Utah Uniform Anatomical Gift Act.
☐ No – Agent shall have no authority regarding donation.
3.4 Limitations. The Agent shall not:
(a) authorize sterilization, electro-convulsive therapy, or experimental research unless expressly permitted in Section 4;
(b) override any valid Do-Not-Resuscitate order executed after this Directive.
[// GUIDANCE: Practitioners may insert additional limitations or culturally specific directives here.]
4. END-OF-LIFE PROVISIONS
4.1 Statement of Intent. If the Declarant is in a terminal condition or persistent vegetative state and lacks capacity, the Declarant’s preference is:
(a) Life-Prolonging Treatment:
☐ Provide all medically indicated treatment to sustain life;
☐ Withhold or withdraw Life-Prolonging Treatment except for comfort care.
(b) Artificial Nutrition & Hydration:
☐ Administer;
☐ Do not administer if death is otherwise imminent.
4.2 Directive Controls. The preferences set forth in Section 4.1 control the Agent’s authority, unless subsequent instructions of the Declarant are conveyed while competent.
4.3 Pain Management. Regardless of other choices, the Declarant requests medication or procedures necessary for relief of pain or discomfort, even if such measures may hasten death.
5. HIPAA AUTHORIZATION
5.1 Authorization. Pursuant to 45 C.F.R. § 164.508 and Utah Code Ann. § 75-2a-106(2)(b), the Declarant authorizes any covered entity to disclose the Declarant’s PHI to the Agent to the fullest extent permitted by law.
5.2 Duration. This authorization is effective on the Effective Date and shall remain in effect until revoked pursuant to Section 8.1 or until the Declarant’s death, whichever occurs first.
6. REPRESENTATIONS & WARRANTIES
6.1 Declarant Capacity. The Declarant represents that he/she is of sound mind and not under duress or undue influence.
6.2 Agent Qualifications. The Declarant has informed the Agent of the appointment and the Agent has agreed to serve.
7. COVENANTS & RESTRICTIONS OF AGENT
7.1 Good-Faith Standard. The Agent shall act in Good Faith and in accordance with the Declarant’s known wishes or, if unknown, in the Declarant’s best interests.
7.2 Record-Keeping. Upon request of an interested party or the state probate court, the Agent shall provide a written report of decisions made under this Directive.
7.3 Conflict of Interest. The Agent shall avoid decisions that materially benefit the Agent’s personal or financial interests over those of the Declarant.
8. DEFAULT & REMEDIES
8.1 Revocation by Declarant. The Declarant may revoke this Directive at any time by:
(a) a signed writing;
(b) an oral statement in the presence of two adult witnesses; or
(c) an act manifesting intent to revoke.
8.2 Removal of Agent. Any interested party may petition the state probate court to remove an Agent who is acting outside the scope of authority or not in Good Faith.
8.3 Court Intervention. The court may issue orders necessary to enforce the Declarant’s wishes, including injunctive relief consistent with Section 10.3.
9. RISK ALLOCATION
9.1 Indemnification. The Declarant agrees to indemnify and hold the Agent harmless from any liability, loss, or expense incurred as a result of Good-Faith actions or omissions under this Directive.
9.2 Limitation of Liability. The Agent shall not be liable for acts or omissions made in Good Faith unless such acts constitute gross negligence, willful misconduct, or bad faith.
9.3 Reliance by Third Parties. A third party may rely upon a photocopy or electronic copy of this Directive and shall not be liable for honoring or refusing to honor the Agent’s instructions when acting in Good Faith.
10. DISPUTE RESOLUTION
10.1 Governing Law. This Directive and any dispute arising hereunder shall be governed by the laws of the State of Utah.
10.2 Forum Selection. The parties submit to the exclusive jurisdiction of the state probate court of [COUNTY], Utah.
10.3 Injunctive Relief. Nothing herein limits the right of any interested party to seek injunctive or declaratory relief to enforce or interpret this Directive.
10.4 Arbitration & Jury Trial. Arbitration is not available, and no jury-trial waiver is provided.
11. GENERAL PROVISIONS
11.1 Amendment. The Declarant may amend this Directive only by executing a subsequent directive in accordance with the Act.
11.2 Severability. If any provision is held unenforceable, the remaining provisions shall remain in full force.
11.3 Integration. This Directive constitutes the entire healthcare power of attorney and advance directive of the Declarant and supersedes all prior inconsistent directives.
11.4 Copies & Electronic Signatures. Photocopies, facsimiles, and electronic signatures shall be deemed originals for all purposes under the Act and Utah’s Uniform Electronic Transactions Act.
12. EXECUTION BLOCK & CERTIFICATION
Declarant Signature
I, [DECLARANT FULL LEGAL NAME], sign my name to this Directive on the Effective Date set forth above.
Signature of Declarant
OPTION A – NOTARY ACKNOWLEDGMENT
State of Utah )
County of [COUNTY] ) ss.
On this [DATE], before me, [NOTARY NAME], a Notary Public, personally appeared [DECLARANT NAME], proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this Directive, and acknowledged that he/she executed the same for the purposes therein contained.
Notary Public
My Commission Expires: _____
OPTION B – TWO ADULT WITNESSES
We declare that the Declarant signed or acknowledged this Directive in our presence and appeared to be of sound mind and under no duress, fraud, or undue influence. Neither of us is the appointed Agent, a healthcare provider for the Declarant, or less than 18 years of age.
| Witness # | Signature | Printed Name & Address | Date |
|---|---|---|---|
| 1 | ______ | ________ | ______ |
| 2 | ______ | ________ | ______ |
[// GUIDANCE: Utah permits either notarization OR two adult witnesses; use one method only. Attach additional explanatory schedules or physician confirmation letters if required by specific institutional policies.]