• LIVING WILL & HEALTHCARE PROXY

  • Basic information
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  • 8. If Married, please complete this section.

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  • A healthcare proxy is someone you trust to make healthcare decisions on your behalf if you are not able to communicate your wishes. 

    Note: If you choose NOT to have a healthcare proxy, you can select no and leave this section blank. 

     

    *If you are married and do not appoint anyone as a healthcare proxy, then your spouse has rights to decide medical treatment for you. 

    **If you are NOT married, and do not appoint anyone as a healthcare proxy, your next of kin may have right to decide medical treatment for you. 

    If "YES" Please complete the following for healthcare procy. A second healthcare proxy may be listed as a backup in case the first one cannot do it. 

  • 10A. First Healthcare Proxy

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  • 10B. Second Healthcare Proxy (backup)

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    • I understand this application and I am emotionally and mentally competent to fill this out.  
    • If No is selected, you cannot continue this application. 

    • Should be Empty:
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