ORS § 127.527

Current through legislation effective January 1, 2024
Section 127.527 - 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:

______________________________________________________________________________

FORM FOR APPOINTING

HEALTH CARE REPRESENTATIVE AND

ALTERNATE HEALTH CARE

REPRESENTATIVE

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).

1.ABOUT ME.

Name: _______________

Date of Birth: _________

Telephone numbers: (Home) _____

(Work) _____ (Cell) _____

Address: __________________

E-mail: _______________

2.MY HEALTH CARE REPRESENTATIVE.

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: _______________

3.MY SIGNATURE.

My signature: _______________

Date: _________

4.WITNESS.

COMPLETE EITHER A OR B WHEN YOU SIGN.

A. NOTARY:

State of ____________

County of ____________

Signed or attested before me on _____,

2___, by _______________.

________________________

Notary Public - State of Oregon

B. WITNESS DECLARATION:

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: _______________

5.ACCEPTANCE BY MY HEALTH CARE REPRESENTATIVE.

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: _________

______________________________________________________________________________

ORS 127.527

2018 c. 36, § 5