![]() This designation shall not become effective unless the Patient is unable to participate in medical treatment decisions.ī. The Patient Advocate/Successor Patient Advocate(s) accept(s) the Patient's designation as stated in this document and agree(s) that:Ī. PATIENT ADVOCATE ACCEPTANCE OF DESIGNATION Nor are we an employee of a life or health insurance provider for, or an employee for a health facility that is treating, the person who signed this instrument, nor are we an employee of a home for the aged where the person who signed this instrument resides. We are not named as the Patient Advocate or a Successor Patient Advocate in this document. We are not the spouse, parent, child, grandchild, sibling, physician, presumptive heir, or known beneficiary of the will at the time of witnessing of the person who signed this instrument. We declare that the person who signed this Document,, is personally known to us, that he/she signed this document in our presence, and that he/she appeared to us to be of sound mind and under no duress, fraud or undue influence. TO BE EFFECTIVE THIS DOCUMENT MUST BE SIGNED IN THE PRESENCE OF TWO WITNESSES. ![]() ![]() If my desires regarding any particular care, custody or medical treatment decision are not known to my Patient Advocate, then the decision should be made taking into consideration my best interests. In exercising this authority, my Patient Advocate shall act consistently with my desires as stated in this document or otherwise made known to my Patient Advocate. Any anatomical donation may be used for transplantation or medical research. Any anatomical donation may be used for medical research only. Any anatomical donation may be used for transplantation only. I specifically authorize my Patient Advocate to donate my entire body upon my death. Including but NOT including I specifically authorize my Patient Advocate to make a disposition of a part or parts of my body as he or she deems appropriate.I specifically authorize my Patient Advocate to donate any organs, tissues, or parts upon my death.I specifically authorize my Patient Advocate to donate the following organs, tissues, or parts upon my death. Subject to any limitations in this document, when I am unable to participate in medical treatment decisions, I grant my Patient Advocate full power and authority to make care, custody, and medical treatment decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so.
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