加州预设医疗护理指示californiaadvancehealthcare.pdfVIP

加州預設醫療護理指示 CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE 包括醫療護理的法律授權 Including Power of Attorney for Health Care IMPRINT / MRN 第一部份 : 委任代理人作出醫療護理上的決定 PART 1: APPOINTING AN AGENT TO MAKE HEALTH CARE DECISIONS 注意: 您必須與您所指定的代理人詳細討論您的意願。 Note: You should discuss your wishes in detail with your designated agent(s). 本人姓名 My name is: _________________________ 出生日期Date of birth: ________ 本人住址My address is: __________________________________________________ 謹此委任代理人。本人希望下述人士協助我作出醫療護理上的決定。 In this document I appoint an agent. I want this person to help make my medical decisions. 您的代理人或候補代理人不可以是Your agent or alternate agent cannot be: 您的主診醫生Your primary physician 在您接受護理地方的工作人員 (除非您與該人有親屬上的關係或彼此為同事) 。 Someone who works where you receive care (unless you are related to that person or you are co-workers).  主要代理人PRIMARY AGENT: 代理人姓名Agent’s Name: ______________________________________________________ 住址Address: __________________________________________________________________ 電話Phone: ___________________________________________________________________ (請註明是住宅電話、工作電話、傳呼機或手提電話。) (Indicate home, work, pager, and cellular phone)  第一候補代理人(假如主要代理人不願意、無法、或有充份理由不能出任。) st 1 ALTERNATE AGENT (If agent is not willing, able, or reasonably available to serve.) 第一候補代理人姓名Name of first alternate agent: ___________________________________ 住址Address: __________________________________________________________________ 電話Phone: ___________________________________________________________________ (請註明是住宅電話、工作電話、傳呼機或手提電話。) (Indicate home, work, pager, and cellular phone)  第二候補代理人(假如主要代理人及第一候補代理人無法或不願意出任。) nd st 2 ALTERNATE AGENT (If agent and 1 alternate are unavailable or unwilling to serve.) 第二候補代理人姓名 Name of second alternate agent: _______________________