HOUSE BILL No. 6126 September 17, 1998, Introduced by Reps. Crissman, Martinez, Scranton, Godchaux, Gilmer, Baird, Bankes, Dobb and Bodem and referred to the Committee on Judiciary. A bill to authorize and regulate health care decisions made by an individual's health care agent for the individual; and to compel compliance with health care decisions made by an individ- ual or made by the individual's health care agent for the individual. THE PEOPLE OF THE STATE OF MICHIGAN ENACT: 1 Sec. 1. This act shall be known and may be cited as the 2 "health care decisions act". 3 Sec. 2. As used in this act: 4 (a) "Advance health care directive" means an individual 5 instruction or a power of attorney for health care. 6 (b) "Capacity" means an individual's ability to understand 7 the significant benefits, risks, and alternatives to proposed 8 health care and to make and communicate a health care decision. 06104'98 GWH 2 1 (c) "Guardian" means a judicially appointed guardian or 2 conservator having authority to make a health care decision for 3 an individual. 4 (d) "Health care" means care, treatment, service, or a pro- 5 cedure to maintain, diagnose, or otherwise affect an individual's 6 physical or mental condition. 7 (e) "Health care agent" means an individual designated in a 8 power of attorney for health care to make a health care decision 9 for the individual granting the power. 10 (f) "Health care decision" means a decision made by an indi- 11 vidual or the individual's health care agent, guardian, or health 12 care surrogate, regarding the individual's health care, includ- 13 ing, but not limited to, all of the following: 14 (i) Selection or discharge of a health care provider or 15 institution. 16 (ii) Approval or disapproval of a diagnostic test, surgical 17 procedure, program of medication, or order not to resuscitate. 18 (iii) A direction to provide, withhold, or withdraw artifi- 19 cial nutrition and hydration or another form of health care. 20 (g) "Health care institution" means an institution, facili- 21 ty, or agency licensed, certified, or otherwise authorized or 22 permitted by law to provide health care in the ordinary course of 23 business. 24 (h) "Health care provider" means an individual licensed, 25 certified, or otherwise authorized or permitted by law to provide 26 health care in the ordinary course of business or practice of a 27 profession. 06104'98 3 1 (i) "Health care surrogate" means an individual, other than 2 a patient's health care agent or guardian, authorized under this 3 act to make a health care decision for the patient. 4 (j) "Individual health care instruction" means an 5 individual's direction concerning a health care decision for the 6 individual. 7 Sec. 3. As used in this act: 8 (a) "Person" means an individual, partnership, corporation, 9 association, governmental entity, or other legal entity. 10 (b) "Physician" means an individual licensed to practice 11 medicine or osteopathic medicine and surgery under article 15 of 12 the public health code, 1978 PA 368, MCL 333.16101 to 333.18838. 13 (c) "Power of attorney for health care" means the designa- 14 tion of a health care agent to make health care decisions for the 15 individual granting the power. 16 (d) "Primary physician" means a physician designated by an 17 individual or the individual's health care agent, guardian, or 18 health care surrogate to have primary responsibility for the 19 individual's health care or, in the absence of a designation or 20 if the designated physician is not reasonably available, a physi- 21 cian who undertakes the responsibility. 22 (e) "Reasonably available" means readily able to be con- 23 tacted without undue effort and willing and able to act in a 24 timely manner considering the urgency of the patient's health 25 care needs. 26 (f) "Supervising health care provider" means the primary 27 physician or, if there is no primary physician or the primary 06104'98 4 1 physician is not reasonably available, the health care provider 2 who has undertaken primary responsibility for an individual's 3 health care. 4 Sec. 4. (1) An adult or emancipated minor may give an indi- 5 vidual health care instruction. The individual health care 6 instruction may be oral or written. The individual health care 7 instruction may be limited to take effect only if a specified 8 condition arises. 9 (2) An adult or emancipated minor may execute a power of 10 attorney for health care, which may authorize a health care agent 11 to make any health care decision the principal could make if the 12 principal had capacity. The power of attorney for health care 13 must be in writing and signed by the principal. The power of 14 attorney for health care remains in effect notwithstanding the 15 principal's later incapacity and may include individual health 16 care instructions. Unless related to the principal by blood, 17 marriage, or adoption, a health care agent shall not be an owner, 18 operator, or employee of a residential long-term health care 19 institution at which the principal is receiving health care. 20 (3) Unless otherwise specified in a power of attorney for 21 health care, the authority of a health care agent is effective 22 only upon a determination that the principal lacks capacity and 23 ceases to be effective upon a determination that the principal 24 has recovered capacity. 25 (4) Unless otherwise specified in a written advance health 26 care directive, an individual's primary care physician shall make 27 the determination that the individual lacks or has recovered 06104'98 5 1 capacity, or that another condition exists that affects an 2 individual health care instruction or the authority of a health 3 care agent. 4 (5) A health care agent shall make a health care decision in 5 accordance with the principal's individual health care instruc- 6 tions, if any, and other wishes to the extent known to the health 7 care agent. Otherwise, the health care agent shall make the 8 decision in accordance with the health care agent's determination 9 of the principal's best interest. In determining the principal's 10 best interest, the health care agent shall consider the 11 principal's personal values to the extent known to the health 12 care agent. 13 (6) A health care agent's health care decision made for the 14 principal is effective without judicial approval. 15 (7) A written advance health care directive may include the 16 individual's nomination of a guardian for the individual. 17 (8) An advance health care directive is valid for purposes 18 of this act if it complies with this act, regardless of when or 19 where executed or communicated. 20 Sec. 5. (1) Except as otherwise provided in this section, 21 an individual may revoke the designation of a health care agent 22 only by a signed writing or by personally informing the supervis- 23 ing health care provider. 24 (2) An individual may revoke all or part of an advance 25 health care directive, other than the designation of a health 26 care agent, at any time and in any manner that communicates an 27 intent to revoke. 06104'98 6 1 (3) A health care provider, health care agent, guardian, or 2 health care surrogate who is informed of the revocation of an 3 advance health care directive shall promptly communicate the fact 4 of the revocation to the supervising health care provider and to 5 each health care institution at which the patient is receiving 6 health care. 7 (4) A decree of annulment, divorce, dissolution of marriage, 8 or legal separation revokes a previous designation of a spouse as 9 health care agent unless otherwise specified in the decree or in 10 a power of attorney for health care. 11 (5) An advance health care directive that conflicts with an 12 earlier advance health care directive revokes the earlier advance 13 health care directive to the extent of the conflict. 14 Sec. 6. (1) An adult or emancipated minor may designate an 15 individual to act as health care surrogate by personally inform- 16 ing the supervising health care provider. In the absence of a 17 designation, or if the designee is not reasonably available, any 18 member of the following classes of the patient's family who is 19 reasonably available, in descending order of priority, may act as 20 health care surrogate: 21 (a) The spouse, unless legally separated. 22 (b) An adult child. 23 (c) A parent. 24 (d) An adult brother or sister. 25 (2) If none of the individuals eligible to act as health 26 care surrogate under subsection (1) are reasonably available, an 27 adult who has exhibited special care and concern for the patient, 06104'98 7 1 who is familiar with the patient's personal values, and who is 2 reasonably available may act as health care surrogate. 3 (3) A health care surrogate shall communicate his or her 4 assumption of authority as promptly as practicable to the members 5 of the patient's family specified in subsection (1) who can be 6 readily contacted. 7 (4) An individual who has made a designation under 8 subsection (1) may, at any time, disqualify another, including a 9 member of the individual's family, from acting as the 10 individual's health care surrogate by a signed writing or by per- 11 sonally informing the supervising health care provider of the 12 disqualification. 13 (5) Unless related to the patient by blood, marriage, or 14 adoption, a health care surrogate may not be an owner, operator, 15 or employee of a residential long-term health care institution at 16 which the patient is receiving health care. 17 (6) A supervising health care provider may require an indi- 18 vidual claiming the right to act as health care surrogate for a 19 patient to provide a written declaration under penalty of perjury 20 stating facts and circumstances reasonably sufficient to estab- 21 lish the claimed authority. 22 Sec. 7. (1) A health care surrogate designated or acting 23 under section 6 may make a health care decision for a patient who 24 is an adult or emancipated minor if the patient has been deter- 25 mined by the primary physician to lack capacity and a health care 26 agent or guardian has not been appointed or the health care agent 27 or guardian is not reasonably available. 06104'98 8 1 (2) If more than 1 member of a class set forth in section 6 2 assumes authority to act as health care surrogate, and he or she 3 does not agree with the other surrogates in that class on a 4 health care decision and the supervising health care provider is 5 so informed, the supervising health care provider shall comply 6 with the decision of a majority of the members of that class who 7 have communicated their views to the supervising health care 8 provider. If the class is evenly divided concerning the health 9 care decision and the supervising health care provider is so 10 informed, that class and all individuals having lower priority 11 are disqualified from making the decision. 12 (3) A health care surrogate shall make a health care deci- 13 sion in accordance with the patient's individual health care 14 instructions, if any, and other wishes of the patient to the 15 extent known to the health care surrogate. Otherwise, the health 16 care surrogate shall make the decision in accordance with the 17 health care surrogate's determination of the patient's best 18 interest. In determining the patient's best interest, the health 19 care surrogate shall consider the patient's personal values to 20 the extent known to the health care surrogate. 21 (4) A health care surrogate's health care decision for the 22 patient is effective without judicial approval. 23 Sec. 8. (1) A guardian shall comply with the ward's indi- 24 vidual health care instructions and may not revoke the ward's 25 advance health care directive unless the appointing court 26 expressly so authorizes. 06104'98 9 1 (2) Absent a court order to the contrary, a health care 2 agent's health care decision takes precedence over that of a 3 guardian. 4 (3) A guardian's health care decision made for the ward is 5 effective without judicial approval. 6 Sec. 9. (1) Before implementing a health care decision made 7 for a patient, a supervising health care provider, if possible, 8 shall promptly communicate to the patient the decision made and 9 the identity of the individual making the decision. 10 (2) A supervising health care provider who knows of the 11 existence of an advance health care directive, a revocation of an 12 advance health care directive, or a designation or disqualifica- 13 tion of a health care surrogate shall promptly record its exis- 14 tence in the patient's health care record and, if it is in writ- 15 ing, shall request a copy and, if one is furnished, shall keep it 16 in the health care record. 17 (3) A primary physician who makes or is informed of a deter- 18 mination that a patient lacks or has recovered capacity, or that 19 another condition exists that affects an individual health care 20 instruction or the authority of a health care agent, guardian, or 21 health care surrogate, shall promptly record the determination in 22 the patient's health care record and communicate the determina- 23 tion to the patient, if possible, and to each individual then 24 authorized to make health care decisions for the patient. 25 Sec. 10. (1) Except as provided in subsections (2) and (3), 26 a health care provider or health care institution providing care 27 to a patient shall comply with all of the following: 06104'98 10 1 (a) A patient's individual health care instruction and a 2 reasonable interpretation of that instruction made by an individ- 3 ual then authorized to make health care decisions for the patient 4 under this act. 5 (b) An individual's health care decision made for the 6 patient if the individual is authorized to make health care deci- 7 sions for the patient under this act. The health care provider 8 or health care institution shall comply with the health care 9 decision to the same extent as if the decision had been made by 10 the patient while having capacity. 11 (2) A health care provider may decline to comply with an 12 individual health care instruction or health care decision for 13 reasons of conscience. A health care institution may decline to 14 comply with an individual health care instruction or health care 15 decision if the instruction or decision is contrary to a policy 16 of the health care institution that is expressly based on reasons 17 of conscience and if the policy was timely communicated to the 18 patient or to an individual then authorized to make health care 19 decisions for the patient under this act. 20 (3) A health care provider or health care institution may 21 decline to comply with an individual health care instruction or 22 health care decision that requires medically ineffective health 23 care or health care contrary to generally accepted health care 24 standards applicable to the health care provider or health care 25 institution. 06104'98 11 1 (4) A health care provider or institution that declines to 2 comply with an individual health care instruction or health care 3 decision shall do all of the following: 4 (a) Promptly inform the patient, if possible, and an indi- 5 vidual authorized to make health care decisions for the patient. 6 (b) Provide continuing care to the patient until a transfer 7 can be effected. 8 (c) Unless the patient or individual authorized to make 9 health care decisions for the patient refuses assistance, immedi- 10 ately make all reasonable efforts to assist in the transfer of 11 the patient to another health care provider or health care insti- 12 tution that is willing to comply with the individual health care 13 instruction or health care decision. 14 (5) A health care provider or health care institution may 15 not require or prohibit the execution or revocation of an advance 16 health care directive as a condition for providing health care. 17 Sec. 11. Unless otherwise specified in an advance health 18 care directive, an individual authorized to make health care 19 decisions for a patient has the same rights as the patient to 20 request, receive, examine, copy, and consent to the disclosure of 21 medical or other health care information. 22 Sec. 12. (1) A health care provider or health care institu- 23 tion acting in good faith and in accordance with generally 24 accepted health care standards applicable to the health care pro- 25 vider or health care institution is not subject to civil or crim- 26 inal liability or to discipline for unprofessional conduct for 1 27 or more of the following: 06104'98 12 1 (a) Complying with a health care decision of an individual 2 apparently having authority to make a health care decision for a 3 patient, including a health care decision to withhold or withdraw 4 health care. 5 (b) Declining to comply with a health care decision of an 6 individual based on a belief that the individual lacks 7 authority. 8 (c) Complying with an advance health care directive and 9 assuming that the advance health care directive was valid when 10 made and has not been revoked or terminated. 11 (2) An individual acting as health care agent or health care 12 surrogate under this act is not subject to civil or criminal 13 liability or to discipline for unprofessional conduct for health 14 care decisions made in good faith and in compliance with this 15 act. 16 Sec. 13. (1) A health care provider or health care institu- 17 tion that intentionally violates this act is subject to liability 18 to the aggrieved individual for damages of $500.00 or actual dam- 19 ages resulting from the violation, whichever is greater, plus 20 reasonable attorney fees. 21 (2) An individual who intentionally falsifies, forges, con- 22 ceals, defaces, or obliterates an individual's advance health 23 care directive or a revocation of an advance health care direc- 24 tive without the individual's consent, or who coerces or fraudu- 25 lently induces an individual to give, to revoke, or not to give 26 an advance health care directive, is subject to liability to that 27 individual for damages of $2,500.00 or actual damages resulting 06104'98 13 1 from the action, whichever is greater, plus reasonable attorney 2 fees. 3 Sec. 14. (1) This act does not affect the right of an indi- 4 vidual to make health care decisions while having capacity to do 5 so. 6 (2) An individual is presumed to have capacity to make a 7 health care decision, to give or revoke an advance health care 8 directive, and to designate or disqualify a health care 9 surrogate. 10 Sec. 15. A copy of a written advance health care directive, 11 revocation of an advance health care directive, or designation or 12 disqualification of a health care surrogate has the same effect 13 as the original. 14 Sec. 16. (1) This act does not create a presumption con- 15 cerning the intention of an individual who has not made or who 16 has revoked an advance health care directive. 17 (2) Death resulting from the withholding or withdrawal of 18 health care in accordance with this act does not for any purpose 19 constitute a suicide or homicide or legally impair or invalidate 20 a policy of insurance or an annuity providing a death benefit, 21 notwithstanding a term of the policy or annuity to the contrary. 22 (3) This act does not authorize mercy killing, assisted sui- 23 cide, euthanasia, or the provision, withholding, or withdrawal of 24 health care, to the extent prohibited by other statutes of this 25 state. 26 (4) This act does not authorize or require a health care 27 provider or health care institution to provide health care 06104'98 14 1 contrary to generally accepted health care standards applicable 2 to the health care provider or health care institution. 3 (5) This act does not authorize a health care agent or 4 health care surrogate to consent to the admission of an individ- 5 ual to a mental health care institution unless the individual's 6 written advance health care directive expressly provides that 7 authority. 8 (6) This act does not affect other state law governing 9 treatment for mental illness of an individual involuntarily com- 10 mitted to a mental health care institution under the mental 11 health code, 1974 PA 258, MCL 330.1001 to 330.2106. 12 Sec. 17. On petition of a patient, the patient's health 13 care agent, guardian, or health care surrogate; a health care 14 provider or health care institution involved with the patient's 15 care; or an individual described in section 6, the circuit court 16 may enjoin or direct a health care decision or order other equi- 17 table relief. The Michigan court rules governing durable powers 18 of attorney for health care or similar rules for expedited pro- 19 ceedings for health care decisions govern a proceeding under this 20 section. 21 Sec. 18. The form provided in this section may be, but is 22 not required to be, used to create an advance health care 23 directive. The other provisions of this act govern the effect of 24 this or another writing used to create an advance health care 25 directive. An individual may complete or modify all or any part 26 of the following form: 06104'98 15 1 ADVANCE HEALTH CARE DIRECTIVE 2 Explanation 3 You have the right to give instructions about your own 4 health care. You also have the right to name someone else to 5 make health care decisions for you. This form lets you do either 6 or both of these things. It also lets you express your wishes 7 regarding donation of organs and the designation of your primary 8 physician. If you use this form, you may complete or modify all 9 or any part of it. You may use a different form. 10 Part 1 of this form is a power of attorney for health care. 11 Part 1 lets you name another individual as your health care agent 12 to make health care decisions for you if you become incapable of 13 making your own decisions or if you want someone else to make 14 those decisions for you now even though you are still capable. 15 You may also name an alternate health care agent to act for you 16 if your first choice is not willing, able, or reasonably avail- 17 able to make decisions for you. Unless related to you, your 18 health care agent may not be an owner, operator, or employee of a 19 residential long-term health care institution at which you are 20 receiving care. 21 Unless the form you sign limits the authority of your health 22 care agent, your health care agent may make all health care deci- 23 sions for you. This form has a place for you to limit the 24 authority of your health care agent. You need not limit the 25 authority of your health care agent if you wish to rely on your 26 health care agent for all health care decisions that may have to 27 be made. If you choose not to limit the authority of your health 06104'98 16 1 care agent, your health care agent will have the right to do all 2 of the following: 3 (a) Consent or refuse consent to care, treatment, service, 4 or a procedure to maintain, diagnose, or otherwise affect a phys- 5 ical or mental condition. 6 (b) Select or discharge a health care provider or health 7 care institution. 8 (c) Approve or disapprove a diagnostic test, surgical proce- 9 dure, program of medication, or order not to resuscitate. 10 (d) Direct the provision, withholding, or withdrawal of 11 artificial nutrition and hydration or another form of health 12 care. 13 Part 2 of this form lets you give specific instructions 14 about any aspect of your health care. Choices are provided for 15 you to express your wishes regarding the provision, withholding, 16 or withdrawal of treatment to keep you alive, including the pro- 17 vision of artificial nutrition and hydration, and the provision 18 of pain relief. Space is also provided for you to add to the 19 choices you have made or for you to write out any additional 20 wishes. 21 Part 3 of this form lets you express an intention to donate 22 your bodily organs and tissues following your death. 23 Part 4 of this form lets you designate a physician to have 24 primary responsibility for your health care. After completing 25 this form, sign and date the form at the end. It is recommended, 26 but not required, that you request 2 other individuals to sign as 27 witnesses. Give a copy of the signed and completed form to your 06104'98 17 1 physician, to each other health care provider you may have, to 2 each health care institution at which you are receiving care, and 3 to the health care agent you have named. You should talk to the 4 individual you have named as health care agent to make sure that 5 he or she understands your wishes and is willing to take the 6 responsibility. 7 You have the right to revoke this advance health care direc- 8 tive or replace this form at any time. 9 PART 1 10 POWER OF ATTORNEY FOR HEALTH CARE 11 (1) DESIGNATION OF AGENT: I designate the following indi- 12 vidual as my health care agent to make health care decisions for 13 me: 14 _________________________________________________________________ 15 (name of individual you choose as health care agent) 16 _________________________________________________________________ 17 (address) (city) (state) (zip code) 18 _________________________________________________________________ 19 (home phone) (work phone) 20 OPTIONAL: If I revoke my health care agent's authority or 21 if my health care agent is not willing, able, or reasonably 22 available to make a health care decision for me, I designate as 23 my first alternate health care agent: 24 _________________________________________________________________ 25 (name of individual you choose as first alternate health care 26 agent) 27 _________________________________________________________________ 28 (address) (city) (state) (zip code) 29 _________________________________________________________________ 30 (home phone) (work phone) 06104'98 18 1 OPTIONAL: If I revoke the authority of my health care agent 2 and first alternate health care agent or if neither is willing, 3 able, or reasonably available to make a health care decision for 4 me, I designate as my second alternate health care agent: 5 _________________________________________________________________ 6 (name of individual you choose as second alternate health care 7 agent) 8 _________________________________________________________________ 9 (address) (city) (state) (zip code) 10 _________________________________________________________________ 11 (home phone) (work phone) 12 (2) HEALTH CARE AGENT'S AUTHORITY: My health care agent is 13 authorized to make all health care decisions for me, including 14 decisions to provide, withhold, or withdraw artificial nutrition 15 and hydration and all other forms of health care to keep me 16 alive, except as I state here: 17 _________________________________________________________________ 18 _________________________________________________________________ 19 _________________________________________________________________ 20 (Add additional sheets if needed.) 21 (3) WHEN HEALTH CARE AGENT'S AUTHORITY BECOMES EFFECTIVE: 22 My health care agent's authority becomes effective when my pri- 23 mary physician determines that I am unable to make my own health 24 care decisions unless I mark the following box. If I mark this 25 box [ ], my health care agent's authority to make health care 26 decisions for me takes effect immediately. 27 (4) HEALTH CARE AGENT'S OBLIGATION: My health care agent 28 shall make health care decisions for me in accordance with this 29 power of attorney for health care, the health care instructions I 06104'98 19 1 give in part 2 of this form, and my other wishes to the extent 2 known to my health care agent. To the extent my wishes are 3 unknown, my health care agent shall make health care decisions 4 for me in accordance with what my health care agent determines to 5 be in my best interest. In determining my best interest, my 6 health care agent shall consider my personal values to the extent 7 known to my health care agent. 8 (5) NOMINATION OF GUARDIAN: If a guardian of my person 9 needs to be appointed for me by a court, I nominate the health 10 care agent designated in this form. If that health care agent is 11 not willing, able, or reasonably available to act as guardian, I 12 nominate the alternate health care agents whom I have named, in 13 the order designated. 14 PART 2 15 INSTRUCTIONS FOR HEALTH CARE 16 If you are satisfied to allow your health care agent to 17 determine what is best for you in making end-of-life decisions, 18 you need not fill out this part of the form. If you do fill out 19 this part of the form, you may strike any wording you do not 20 want. 21 (6) END-OF-LIFE DECISIONS: I direct that my health care 22 providers and others involved in my care provide, withhold, or 23 withdraw treatment in accordance with the choice I have marked 24 below: 25 [ ] (a) Choice not to prolong life 26 I do not want my life to be prolonged if any of the 27 following are true: 06104'98 20 1 (i) I have an incurable and irreversible condition that will 2 result in my death within a relatively short time. 3 (ii) I become unconscious and, to a reasonable degree of 4 medical certainty, I will not regain consciousness. 5 (iii) The likely risks and burdens of treatment would out- 6 weigh the expected benefits. 7 [ ] (b) Choice to prolong life 8 I want my life to be prolonged as long as possible within 9 the limits of generally accepted health care standards. 10 (7) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutri- 11 tion and hydration must be provided, withheld, or withdrawn in 12 accordance with the choice I have made in paragraph (6) unless I 13 mark the following box. If I mark this box [ ], artificial 14 nutrition and hydration must be provided regardless of my condi- 15 tion and regardless of the choice I have made in paragraph (6). 16 (8) RELIEF FROM PAIN: Except as I state in the following 17 space, I direct that treatment for alleviation of pain or discom- 18 fort be provided at all times, even if it hastens my death: 19 _________________________________________________________________ 20 _________________________________________________________________ 21 (9) OTHER WISHES: (If you do not agree with any of the 22 optional choices above and wish to write your own, or if you wish 23 to add to the health care instructions you have given above, you 24 may do so here.) I direct that: 25 _________________________________________________________________ 26 _________________________________________________________________ 27 (Add additional sheets if needed.) 06104'98 21 1 PART 3 2 DONATION OF ORGANS AT DEATH 3 (OPTIONAL) 4 (10) Upon my death (mark applicable box) 5 [ ] (a) I give any needed organs, tissues, or parts. 6 [ ] (b) I give the following organs, tissues, or parts 7 only 8 _________________________________________________________________ 9 (c) My gift is for the following purposes (strike any of the 10 following you do not want): 11 (i) Transplant. 12 (ii) Therapy. 13 (iii) Research. 14 (iv) Education. 15 PART 4 16 PRIMARY PHYSICIAN 17 (OPTIONAL) 18 (11) I designate the following physician as my primary 19 physician: 20 _________________________________________________________________ 21 (name of physician) 22 _________________________________________________________________ 23 (address) (city) (state) (zip code) 24 _________________________________________________________________ 25 (phone) 26 OPTIONAL: If the physician I have designated above is not 27 willing, able, or reasonably available to act as my primary 28 physician, I designate the following physician as my primary 29 physician: 06104'98 22 1 _________________________________________________________________ 2 (name of physician) 3 _________________________________________________________________ 4 (address) (city) (state) (zip code) 5 _________________________________________________________________ 6 (phone) 7 (12) EFFECT OF COPY: A copy of this form has the same 8 effect as the original. 9 (13) SIGNATURES: Sign and date the form here: 10 ______________________________ _____________________________ 11 (date) (sign your name) 12 ______________________________ _____________________________ 13 (address) (print your name) 14 ______________________________ 15 (city) (state) 16 (Optional) SIGNATURES OF WITNESSES: 17 First witness Second witness 18 ______________________________ _____________________________ 19 (print name) (print name) 20 ______________________________ _____________________________ 21 (address) (address) 22 ______________________________ _____________________________ 23 (city) (state) (city) (state) 24 ______________________________ _____________________________ 25 (signature of witness) (signature of witness) 26 ______________________________ _____________________________ 27 (date) (date) 28 Sec. 19. (1) This act shall be applied and construed to 29 effectuate its general purpose to make uniform the law with 30 respect to the subject matter of this act among states enacting 31 it. 32 (2) If a provision of this act or its application to a 33 person or circumstance is held invalid, the invalidity does not 06104'98 23 1 affect other provisions or applications of this act that can be 2 given effect without the invalid provision or application, and to 3 this end the provisions of this act are severable. 4 (3) This act takes effect January 1, 1999. 06104'98 Final page. GWH