R.I. Gen. Laws § 23-4.10-2
The statutory form of durable power of attorney is as follows:
STATUTORY FORM DURABLE POWER OF ATTORNEY FOR HEALTH CARE
WARNING TO PERSON EXECUTING THIS DOCUMENT
This is an important legal document which is authorized by the general laws of this state. Before executing this document, you should know these important facts:
You must be at least eighteen (18) years of age and a resident of the state for this document to be legally valid and binding.
This document gives the person you designate as your agent (the attorney in fact) the power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known.
Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.
Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection at the time, and health care necessary to keep you alive may not be stopped or withheld if you object at the time.
This document gives your agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. This power is subject to any statement of your desires and any limitation that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your agent to make health care decisions for you if your agent:
Unless you specify a specific period, this power will exist until you revoke it. Your agent's power and authority ceases upon your death except to inform your family or next of kin of your desire, if any, to be an organ and tissue owner.
You have the right to revoke the authority of your agent by notifying your agent or your treating doctor, hospital, or other health care provider orally or in writing of the revocation.
Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.
This document revokes any prior durable power of attorney for health care.
You should carefully read and follow the witnessing procedure described at the end of this form. This document will not be valid unless you comply with the witnessing procedure.
If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.
Your agent may need this document immediately in case of an emergency that requires a decision concerning your health care. Either keep this document where it is immediately available to your agent and alternate agents or give each of them an executed copy of this document. You may also want to give your doctor an executed copy of this document.
_________
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(insert your name and address)
do hereby designate and appoint: _________
_________
(insert name, address, and telephone number of one individual only as your agent to make health care decisions for you. None of the following may be designated as your agent:
(If you want to limit the authority of your agent to make health care decisions for you, you can state the limitations in paragraph (4) ("Statement of Desires, Special Provisions, and Limitations") below. You can indicate your desires by including a statement of your desires in the same paragraph.)
In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated below:
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Initial if applicable:
[ ] In the event of my death, I request that my agent inform my family/next of kin of my desire to be an organ and tissue donor, if possible.
(You may attach additional pages if you need more space to complete your statement. If you attach additional pages, you must date and sign EACH of the additional pages at the same time you date and sign this document.)
(If you want to limit the authority of your agent to receive and disclose information relating to your health, you must state the limitations in paragraph (4) ("Statement of desires, special provisions, and limitations") above.)
This durable power of attorney for health care expires on
_________
(Fill in this space ONLY if you want the authority of your agent to end on a specific date.)
If the person designated as my agent in paragraph (1) is not available or becomes ineligible to act as my agent to make a health care decision for me or loses the mental capacity to make health care decisions for me, or if I revoke that person's appointment or authority to act as my agent to make health care decisions for me, then I designate and appoint the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below:
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(Insert name, address, and telephone number of first alternate agent.)
_________
(Insert name, address, and telephone number of second alternate agent.)
DATE AND SIGNATURE OF PRINCIPAL
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
I sign my name to this Statutory Form Durable Power of Attorney for Health Care on _________ at _________
(Date) (City)
_______________
(State)
_______________
(You sign here)
(THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED BY ONE NOTARY PUBLIC OR TWO (2) QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS POWER OF ATTORNEY.)
STATEMENT OF WITNESSES
(This document must be witnessed by two (2) qualified adult witnesses or one (1) notary public. None of the following may be used as a witness:
I declare under penalty of perjury that the person who signed or acknowledged this document is personally known to me to be the principal, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, an employee of a health care provider, the operator of a community care facility, nor an employee of an operator of a community care facility.
Option 1 - Two (2) Qualified Witnesses:
Signature: _________ Residence Address: ________
Print Name: _________ _________________
Date: _________ _________________
Signature: _________ Residence Address: ________
Print Name: _________ _________________
Date: _________ _________________
Option 2 - One Notary Public
Signature: __________________ , Notary Public
Print Name: __________________
Date: _____________
My commission expires on: ______________
(AT LEAST ONE OF THE ABOVE WITNESSES OR THE NOTARY PUBLIC MUST ALSO SIGN THE FOLLOWING DECLARATION.)
I further declare under penalty of perjury that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.
Signature: _________
Print Name: _________
R.I. Gen. Laws § 23-4.10-2