DURABLE POWER OF ATTORNEY FOR HEALTH CARE
(Washington State)
[// GUIDANCE: This template integrates (i) Washington’s Uniform Power of Attorney Act, Wash. Rev. Code § 11.125, (ii) the Natural Death Act/Health-Care Directive statute, Wash. Rev. Code § 70.122, and (iii) the HIPAA Privacy Rule, 45 C.F.R. pts. 160 & 164. Customize all bracketed items and confirm witness/notary requirements based on the execution method selected.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
- Exhibit A – Optional End-of-Life Directive Summary
1. DOCUMENT HEADER
1.1 Title
DURABLE POWER OF ATTORNEY FOR HEALTH CARE (“Agreement”)
1.2 Parties
(a) Principal: [PRINCIPAL FULL LEGAL NAME], residing at [ADDRESS]
(b) Agent (Attorney-in-Fact): [PRIMARY AGENT FULL LEGAL NAME], residing at [ADDRESS]
(c) Successor Agent(s) (if any): [ALTERNATE AGENT NAME(S)]
1.3 Effective Date
This Agreement is effective on the later of (i) the date executed by the Principal, or (ii) the date specified in Section 3.6 (“Effective Date & Durability”).
1.4 Governing Law
This Agreement is governed by the laws of the State of Washington, without regard to its conflict-of-laws rules.
1.5 Recitals
A. Principal desires to appoint an agent to make health-care decisions on the Principal’s behalf when the Principal is unable to do so.
B. This Agreement is intended to constitute a “durable power of attorney” for health care under Wash. Rev. Code § 11.125 and to incorporate the Principal’s directives under Wash. Rev. Code § 70.122.
C. The parties desire to set forth their respective rights, duties, and obligations, subject to the good-faith standards and limitations contained herein.
2. DEFINITIONS
For purposes of this Agreement, the following capitalized terms have the meanings set forth below. Terms defined herein apply equally to singular and plural forms. Alphabetical listing:
“Advance Directive” – A written instruction recognized under RCW 70.122 that expresses the Principal’s wishes regarding life-sustaining treatment and other end-of-life care.
“Agent” – The person or persons designated in Section 1.2(b) and (c) who are authorized to act for the Principal under this Agreement.
“Good Faith” – Honesty in fact and observance of reasonable standards of health-care decision-making in accordance with RCW 11.125 and this Agreement.
“Health-Care Decision” – Any consent, refusal, withdrawal, or request with respect to health-care services, including but not limited to surgery, medication, artificial nutrition and hydration, and admission to or discharge from health-care facilities.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, and its implementing regulations at 45 C.F.R. pts. 160 & 164.
“Incapacity” – A determination by a qualified health-care professional that the Principal lacks the ability to understand the significant benefits, risks, and alternatives to proposed health-care decisions and to communicate a decision.
“Principal” – The individual granting authority herein, as identified in Section 1.2(a).
“Successor Agent” – An individual designated to serve if the Agent is unwilling, unable, or unavailable to act.
3. OPERATIVE PROVISIONS
3.1 Grant of Authority
The Principal hereby appoints the Agent to make any and all Health-Care Decisions on the Principal’s behalf, subject to the limitations in this Agreement and applicable law.
3.2 Specific Authorities
Without limiting the generality of Section 3.1, the Agent may:
(a) Provide or withhold informed consent to diagnosis, treatment, or procedures;
(b) Admit, transfer, or discharge the Principal from hospitals, nursing homes, or similar facilities;
(c) Hire and dismiss health-care providers or caregivers;
(d) Access, disclose, or authorize disclosure of health information, including mental-health and substance-use information, consistent with Section 3.5 (HIPAA Authorization);
(e) Make decisions regarding organ donation, autopsy, and disposition of remains;
(f) Apply for public or private benefits (e.g., Medicare, Medicaid) related to health-care costs;
(g) Sign and deliver any documents reasonably necessary to implement the foregoing powers.
3.3 Limitations on Authority
(a) The Agent shall act in Good Faith and in accordance with any written or oral instructions of the Principal, including but not limited to the Advance Directive attached as Exhibit A.
(b) The Agent shall not have authority to make any decision the Principal expressly prohibits herein.
[// GUIDANCE: Insert any desired specific limitations, e.g., “Agent may not authorize psychosurgery”].
3.4 End-of-Life Provisions
(a) If the Principal has an applicable Advance Directive, the Agent shall ensure compliance with that directive.
(b) In the absence of a written directive, the Agent shall decide consistent with the Principal’s known wishes or, if unknown, the Principal’s best interests, taking into account pain, dignity, financial cost, and religious or moral beliefs.
3.5 HIPAA Authorization
The Principal authorizes all covered entities to disclose to the Agent any and all protected health information (“PHI”) necessary for the Agent to fulfill duties under this Agreement. This authorization is intended to be a valid “authorization” under 45 C.F.R. § 164.508 and survives the Principal’s death to the extent PHI is required for decision-making regarding post-mortem matters.
3.6 Effective Date & Durability
(a) This authority becomes effective:
[SELECT ONE] ☐ immediately upon execution ☐ upon certification of Incapacity by [ONE / TWO] licensed physician(s).
(b) The Agent’s authority is durable and continues notwithstanding the Principal’s Incapacity but terminates as provided in Section 6.
3.7 Consideration
No monetary consideration is given or required for the grant of authority herein.
4. REPRESENTATIONS & WARRANTIES
4.1 By the Principal
(a) Capacity: Principal represents that Principal is at least eighteen (18) years old and of sound mind.
(b) Voluntariness: Execution is voluntary and without undue influence.
4.2 By the Agent
Agent represents and warrants that Agent:
(a) Is willing and able to serve;
(b) Will act in Good Faith and in accordance with this Agreement and Washington law; and
(c) Has no disqualifying conflict of interest not disclosed to the Principal.
4.3 Survival
All representations and warranties survive revocation or termination to the extent necessary to enforce Section 7 (Risk Allocation).
5. COVENANTS & RESTRICTIONS
5.1 Agent shall:
(a) Consult the Principal to the extent possible before making any Health-Care Decision;
(b) Maintain contemporaneous records of material decisions;
(c) Promptly inform Successor Agent(s) of any inability to act.
5.2 Agent shall not:
(a) Delegate authority except to a duly-appointed Successor Agent;
(b) Make any gift of the Principal’s property other than as incidental to carrying out Health-Care Decisions;
(c) Receive compensation beyond reasonable out-of-pocket expenses unless expressly authorized at [SECTION/EXHIBIT].
6. DEFAULT & REMEDIES
6.1 Revocation by Principal
The Principal may revoke this Agreement in whole or in part at any time by:
(a) A written instrument executed by the Principal; or
(b) Personally informing the attending physician or health-care provider.
6.2 Automatic Termination
This Agreement terminates upon the earliest of:
(a) Death of the Principal;
(b) Court appointment of a guardian for the Principal’s person, unless the court orders otherwise;
(c) Formal resignation, incapacity, or death of the Agent with no Successor Agent available.
6.3 Judicial Relief
Any interested person may petition the appropriate Washington superior court for review, removal, or clarification of the Agent’s authority.
6.4 Fees and Costs
In any action to enforce this Agreement, the prevailing party is entitled to reasonable attorney fees and costs.
7. RISK ALLOCATION
7.1 Indemnification
The Principal agrees to indemnify and hold harmless the Agent from any loss, liability, or expense (including reasonable attorney fees) incurred by reason of the Agent’s Good-Faith actions under this Agreement.
7.2 Limitation of Liability
No Agent shall be liable for any act or omission made in Good Faith and in substantial compliance with this Agreement and applicable law.
7.3 Insurance
[OPTIONAL] The Principal shall maintain health-care or liability insurance covering decisions made pursuant to this Agreement, naming the Agent as an additional insured.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Agreement is construed in accordance with the laws of the State of Washington (“state_healthcare_law”).
8.2 Forum Selection
Exclusive venue and jurisdiction lie with the probate division of the [COUNTY] Superior Court (“state_probate_court”).
8.3 Arbitration
Arbitration is expressly disclaimed (“not_available”).
8.4 Jury Waiver
No jury waiver is provided (“not_available”).
8.5 Injunctive Relief
Nothing herein restricts any party from seeking injunctive or declaratory relief to enforce the Principal’s health-care directive (“healthcare_directive”).
9. GENERAL PROVISIONS
9.1 Amendment & Waiver
This Agreement may be amended only by a written instrument signed by the Principal and acknowledged in the same manner as this Agreement. No waiver of rights is effective unless in writing.
9.2 Assignment & Delegation
The Agent may not assign or delegate duties except to a Successor Agent expressly named herein.
9.3 Successors & Assigns
This Agreement binds and benefits the Principal, the Agent(s), and their respective heirs, successors, and permitted assigns.
9.4 Severability
If any provision is held invalid, the remaining provisions remain enforceable, and the invalid provision shall be reformed to the minimum extent necessary to effectuate the parties’ intent.
9.5 Integration
This Agreement constitutes the entire understanding regarding the subject matter and supersedes all prior powers of attorney for health care executed by the Principal.
9.6 Counterparts
This Agreement may be executed in counterparts, each of which is deemed an original, and all of which constitute one instrument.
9.7 Electronic Signatures
Electronic signatures and notarizations comply with Wash. Rev. Code ch. 1.80 (Uniform Electronic Transactions Act) and are binding.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the Principal executes this Durable Power of Attorney for Health Care as of the Effective Date.
10.1 Principal
[PRINCIPAL NAME] – Principal
Date: _____
10.2 Agent Acceptance
I, the undersigned, accept the appointment as Agent and agree to act in Good Faith.
[AGENT NAME] – Agent
Date: _____
10.3 Successor Agent Acceptance (if any)
[ALTERNATE AGENT NAME] – Successor Agent
Date: _____
10.4 Notarization / Witness Attestation
[SELECT ONE OPTION BELOW—STRIKE OUT THE OTHER]
Option A – Notary Acknowledgment
State of Washington )
County of ____) ss.
On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], known to me or proved on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument, and acknowledged executing the same.
Notary Public
My commission expires: ____
Option B – Two Witnesses (must meet statutory criteria)
We declare that the Principal appears to be of sound mind and under no duress, fraud, or undue influence.
Witness 1: _____ Address: ____ Date: ______
Witness 2: _____ Address: ____ Date: ______
[// GUIDANCE: Witnesses may NOT be (i) related to the Principal by blood or marriage, (ii) entitled to any portion of the Principal’s estate, or (iii) the Principal’s attending physician, as per RCW 70.122.030.]
11. EXHIBIT A – OPTIONAL END-OF-LIFE DIRECTIVE SUMMARY
[PLACEHOLDER: Insert or attach a full Washington “Health Care Directive” (Living Will) or summarize specific instructions—e.g., artificial nutrition, hydration, resuscitation, pain control, organ donation, religious considerations.]
[// GUIDANCE: File a copy of this executed document with the Principal’s primary care provider, local hospital, and any care facility. Provide copies to all named Agents. Consider registering with the Washington Advance Directive Registry if available.]