ORS 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:

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 (Withdrawal of life-sustaining procedures) (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: _________

[2018 c.36 §5]

Source: Section 127.527 — Form for appointing health care representative, https://www.­oregonlegislature.­gov/bills_laws/ors/ors127.­html.

127.002
Definitions for ORS 127.005 to 127.045
127.005
When power of attorney in effect
127.015
Revocation of power of attorney
127.025
Authority under power of attorney recognizable regardless of date of execution
127.035
Limitations on liability of person reasonably relying on power of attorney
127.045
Duty of agent under power of attorney
127.505
Definitions for ORS 127.505 to 127.660
127.507
Capable adults may make own health care decisions
127.510
Appointment of health care representative and alternate health care representative
127.515
Execution
127.520
Persons not eligible to serve as health care representative
127.525
Acceptance of appointment
127.527
Form for appointing health care representative
127.529
Form of advance directive
127.532
Appointment
127.533
Duties
127.535
Authority of health care representative
127.540
Limitations on authority of health care representative
127.545
Revocation of advance directive or health care decision
127.550
Petition for judicial review of advance directives
127.555
Designation of attending physician or health care provider
127.560
Provisions not exclusive
127.565
Independent medical judgment of provider
127.570
Mercy killing
127.575
Instrument presumed valid
127.580
Presumption of consent to artificially administered nutrition and hydration
127.625
Providers under no duty to participate in withdrawal or withholding of certain health care
127.635
Withdrawal of life-sustaining procedures
127.640
Physician to determine that conditions met before withdrawing or withholding certain health care
127.642
Principal to be provided with certain care to insure comfort and cleanliness
127.646
Definitions for ORS 127.646 to 127.654
127.649
Health care organizations required to have written policies and procedures on providing information on patient’s right to make health care decisions
127.652
Time of providing information
127.654
Scope of requirement
127.658
Effect of ORS 127.505 to 127.660 on previously executed advance directives
127.660
Short title
127.663
Definitions for ORS 127.663 to 127.684
127.666
Establishment of registry
127.669
Oregon Health Authority not required to perform certain acts
127.672
POLST not required
127.678
Confidentiality
127.681
Immunity from liability
127.684
Short title
127.700
Definitions for ORS 127.700 to 127.737
127.702
Persons who may make declaration for mental health treatment
127.703
Required policies regarding mental health treatment rights information
127.705
Designation of attorney-in-fact for decisions about mental health treatment
127.707
Execution of declaration
127.710
Operation of declaration
127.712
Scope of authority of attorney-in-fact
127.715
Prohibitions against requiring person to execute or refrain from executing declaration
127.717
Declaration to be made part of medical record
127.720
Circumstances in which physician or provider may disregard declaration
127.722
Revocation of declaration
127.725
Limitations on liability of physician or provider
127.727
Persons prohibited from serving as attorney-in-fact
127.730
Persons prohibited from serving as witnesses to declaration
127.732
Withdrawal of attorney-in-fact
127.736
Form of declaration
127.737
Certain other laws applicable to declaration
127.760
Consent to health care services by person appointed by hospital
127.765
Health care advocate
127.800
§1.01. Definitions
127.805
§2.01. Who may initiate a written request for medication
127.810
§2.02. Form of the written request
127.815
§3.01. Attending physician responsibilities
127.820
§3.02. Consulting physician confirmation
127.825
§3.03. Counseling referral
127.830
§3.04. Informed decision
127.835
§3.05. Family notification
127.840
§3.06. Written and oral requests
127.845
§3.07. Right to rescind request
127.850
§3.08. Waiting periods
127.855
§3.09. Medical record documentation requirements
127.860
§3.10. Residency requirement
127.865
§3.11. Reporting requirements
127.870
§3.12. Effect on construction of wills, contracts and statutes
127.875
§3.13. Insurance or annuity policies
127.880
§3.14. Construction of Act
127.885
§4.01. Immunities
127.890
§4.02. Liabilities
127.892
Claims by governmental entity for costs incurred
127.895
§5.01. Severability
127.897
§6.01. Form of the request
127.995
Penalties
Green check means up to date. Up to date