Following guidelines set by federal regulations, we would like to inform you of your right to make personal health care decisions. This may include the right to accept or refuse medical/surgical treatment and the right to formulate Advance Directives. You may find it helpful to provide copies of these documents for: hospitals, physicians, family members, friends, and clergy. Remember to store your own copy in a safe place where it can be easily found. If you have already written an Advance Directives plan, please provide us with a copy to place in your medical chart.
Each of these documents must be notarized. Clay County Medical Center provides free notary services. Please let hospital personnel know if you need assistance.
Durable Power of Attorney (DPOA)
If you are no longer able to speak for yourself, a Durable Power of Attorney is used to appoint someone to make decisions about medical care, including decisions about life-sustaining treatment. It goes into effect when your doctor determines that you are unable to communicate healthcare decisions. This person is often called a Healthcare Proxy or Healthcare Agent.
>>Download DPOA Form.pdf
In the event of a terminal condition or a situation when you are no longer able to make medical decisions, the Living Will specifies your preferences regarding medical care. The Living Will only become effective when you are unable to make medical decisions.
>>Download Living Will Form.pdf
Patient Self-Determination Act
A federal law requiring hospitals to “provide written information” to adult in-patients about an “an individual’s right … to make decisions concerning …medical care, including the right to accept or refusal of medical or surgical treatment and the right to formulate Advance Directives” is known as the Patient Self-Determination Act.
>>Download Self-Determination Act Form.pdf