Form for appointing health care representative

A form for appointing a health care representative and an alternate health care representative must be written in substantially the following form: ______________________________________________________________________________ This form may be used in Oregon to choose a person to make health care decisions for you if you become too sick to speak for yourself. The person is called a health care representative. • If you have completed a form appointing a health care representative in the past, this new form will replace any older form. • You must sign this form for it to be effective. You must also have it witnessed by two witnesses or a notary. Your appointment of a health care representative is not effective until the health care representative accepts the appointment. • If you become too sick to speak for yourself and do not have an effective health care representative appointment, a health care representative will be appointed for you in the order of priority set forth in ORS 127.635 (2). Name: _______________ Date of Birth: _________ Telephone numbers: (Home) _____ (Work) _____ (Cell) _____ Address: __________________ E-mail: _______________ I choose the following person as my health care representative to make health care decisions for me if I can’t speak for myself. Name: _______________ Relationship: _________ Telephone numbers: (Home) _____ (Work) _____ (Cell) _____ Address: __________________ E-mail: _______________ I choose the following people to be my alternate health care representatives if my first choice is not available to make health care decisions for me or if I cancel the first health care representative’s appointment. First alternate health care representative: Name: _______________ Relationship: _________ Telephone numbers: (Home) _____ (Work) _____ (Cell) _____ Address: __________________ E-mail: _______________ Second alternate health care representative: Name: _______________ Relationship: _________ Telephone numbers: (Home) _____ (Work) _____ (Cell) _____ Address: __________________ E-mail: _______________ My signature: _______________ Date: _________ State of ____________ County of ____________ Signed or attested before me on _____, 2___, by _______________. ________________________ Notary Public - State of Oregon The person completing this form is personally known to me or has provided proof of identity, has signed or acknowledged the person’s signature on the document in my presence and appears to be not under duress and to understand the purpose and effect of this form. In addition, I am not the person’s health care representative or alternate health care representative, and I am not the person’s attending health care provider. Witness Name (print): ________ Signature: _______________ Date: _______________ Witness Name (print): ________ Signature: _______________ Date: _______________ I accept this appointment and agree to serve as health care representative. Health care representative: Printed name: _______________ Signature or other verification of acceptance: _______________ Date: _________ First alternate health care representative: Printed name: _______________ Signature or other verification of acceptance: _______________ Date: _________ Second alternate health care representative: Printed name: _______________ Signature or other verification of acceptance: _______________ Date: _________ ______________________________________________________________________________