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Forms
Do Not Resuscitate Order – DNR
This is a state specific form specifying your desires that, should you experience cardiac or pulmonary failure in a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that you be permitted to die naturally. A do not resuscitate (DNR) order is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. Unless given other instructions, hospital staff will try to help all patients whose heart has stopped or who have stopped breathing. A DNR order is put in your medical chart by your doctor. DNR orders are accepted by doctors and hospitals in all states.
Health Care Proxy - Designation of Health Care Surrogate
This form allows you to designate a surrogate to make health care decisions for you if you are determined to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures.
Living Will
This Living Will form allows you to express your wishes and desires if it is determined that your death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process. It is a declaration that such procedures be withheld or withdrawn, and that you be permitted to die naturally with only the administration of medication, or the performance of any medical procedure deemed necessary to provide you with comfortable care.
Advanced Health-Care Directive
You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding the designation of your primary physician. If you use this form, you may complete or modify all or any party of it. You are free to use a different form. Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now and even though you are still capable. You may name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator, or employee of a residential long term health care institution at which you are receiving care. Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to: (a) Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental condition; (b) Select or discharge health care providers and institutions; (c) Approve or disapprove diagnostic tests, surgical procedures, programs or medication, and orders not to resuscitate; and (d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care. Part 2 of this form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provisions, withholding, or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief. Space is provided for you to add to the choices you have made or for you to write out any additional wishes. Part 3 of this form lets you designate a physician to have primary responsibility for your health care. After completing this form, sign and date the form at the end and have the form witnessed by one of the two alternative methods listed below, Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health care institution at which you are receiving care, and to any health care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility. You have the right to revoke this advance health care directive or replace this form at any time.
HIPPA Release Form
In response to growing concerns about keeping health information private, Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The legislation includes a privacy rule that creates national standards to protect individuals' personal health information. HIPAA, requires health care professionals to protect privacy and create standards for electronic transfers of health data. HIPAA came about because of the public's concern about how health care information is used. HIPAA gives patients more control over their own health information. HIPAA requires health care providers to follow certain rules to protect the privacy of patients' health information. For instance, employees are not allowed to access information on patients unless they need the information to perform their jobs.