Medical Matters

1.  Authorization to Share Medical Information  (General Authorization - Not Applicable to Psychotherapy
     or Psychiatric Matters)

2.  Authorization to Share Medical Information  (Including Behavioral and Mental Health Disorders)

3.  Authorization to Share Medical Information (Alcohol and/or Drug Abuse or Chemical Dependency,
     Excluding Psychotherapy Notes)

• New privacy laws prohibit medical professionals or facilities from sharing medical information with anyone unless they have written authorization. With a Medical Authorization, you can allow friends and family members to be kept informed of your medical condition during medical emergencies.

• In order for someone to lend a hand in the future and be allowed to (1) pick up your prescriptions from the pharmacy, (2) pick up your x-rays or other medical tests from a hospital or other facility, (3) or help with any type of medical tasks, that person must first have your written authorization.

• If you want to be informed of the medical condition of your close friends and family members in a medical emergency or crisis, ask them to sign a Medical Authorization directing medical personnel to share that information with you.

• Once you have completed the Authorization, give a copy to the Authorized Party or Parties so they are prepared for an emergency.

• If you decide to withdraw approval for access to your medical information from someone to whom you earlier authorized—and to whom you gave a copy of the earlier Authorization—use this Revocation to revoke your approval.  If you never gave a copy of the Authorization to that person or to anyone else, just destroy it and no revocation is needed.

6.  Authorization for Hospital Visitation  

• Because most hospitals limit visitors to immediate family members if you aren’t able to instruct them otherwise, it is important to be prepared for the unexpected by completing this LivingForm authorizing those that you would like to be able to visit you in the hospital during an emergency or crisis (other than immediate family members). Once you have completed the LivingForm, give a copy to authorized parties so they can easily produce it to medical personal in an emergency or crisis and be able to visit you in a hospital or other medical facility.

• Use this Revocation if you decide to withdraw an earlier authorization for visitation to a medical facility. 
  If you never gave anyone a copy of the original Authorization, just destroy it and no Revocation is needed.

• No matter your age, an auto accident, other accident or unexpected illness may require a stay in a rehabilitation, assisted living or other facility while you recuperate.  Once you need one of these facilities, it is too late to do your homework and visit the various options in your community so you know where you would be more comfortable under the circumstances. Take the time to visit the facilities in your community and document your first three choices of rehabilitation, assisted living and nursing homes so that if you ever need their services, you can make your choices known and your family and friends will know of your wishes (if you are unable to make them known yourself).  Either give family and friends a copy of this LivingForm or tell them where to find your LivingForms so your wishes will be immediately known if you can’t speak for yourself.

• This Authorization allows you to detail your wishes upon your death. You decide whether you want a funeral, burial, memorial, or other service upon your death; who you want to officiate; what kind of music to play; what price range of your casket if you desire one; and all aspects of your final arrangements.  You can also designate who you would like to oversee these arrangements after your death. If you have already prepaid for a funeral, provide the details so those you leave behind know who to contact and what services are included in the pre-purchase arrangements. If you prefer, you can designate someone to make all of the arrangements for you.If you designate a particular person to oversee the arrangements you specify or to make all decisions for you, give them a copy of this Authorization so they can be prepared to undertake your requests upon your death.

10.  Revocation of Authorization to Make Funeral and Burial Arrangements

• If you change your mind about having someone else make all of your arrangements for you OR who you would like to be responsible for carrying out your express wishes, simply revoke the Authorization and complete a new one. If you never gave a copy of the original Authorization to anyone else, just destroy it and make a new one.

11.  Authorization to Direct and Approve Medical Treatment/Care (Short Form; not available in all states)

12.  Revocation of Authorization to Direct and Approve Medical Treatment/Care (Short Form; not available
        in all states)

13.  Living Will Directive

14.  Revocation of Living Will Directive

15.  Health Care Power of Attorney

16.  Revocation of Health Care Power of Attorney

• If you are hospitalized or are otherwise unable to challenge your insurance company over your healthcare benefits to ensure that you are getting all of the benefits to which you are entitled, make sure that someone else has the authority to contact your company (or companies) and act as your advocate.This authorization allows you to give others authorization to access any of your insurance policies that you designate:  auto, life, property, disability, etc.  This allows them to make claims on your behalf, discuss premium or policy information for you or anything else you would like them to do and under what circumstances.Give a copy of this Authorization to the authorized party as soon as you complete it so they are able to immediately help in an emergency or crisis.

• Allows you to change who you would like to be your advocate with your private insurance companies.  If you never gave a copy of the original Authorization to any one else, just destroy it. You can then get a new Authorization if you would like to give someone new the right to be your advocate in connection with government benefits.

• If you are unable or don’t feel up to dealing with the government to process claims and make certain you are getting all the benefits to which you are entitled with Medicare, Social Security, Disability, or other government benefits and you would like to empower someone else to help you, you must first give them written authorization.  Otherwise government personnel will not be allowed to discuss your benefits with them.Give a copy of the Authorization to any authorized party so they can be prepared to help you in an emergency or crisis. If you want to be able to help other friends or family members in a crunch, give them this LivingForm and ask them to fill it out giving you authority to help them with their government insurance benefits.

• Use this Revocation if you no longer want a previously authorized person to have access to your government insurance benefits.  If you didn’t give a copy of the original Authorization to anyone, just destroy it and there is no need to sign a Revocation.

Personal and Household Matters
 

21.  Important Personal Information

• In order for others to help you in an emergency or crisis, they will need access to information like the names and phone numbers of your doctors, lawyers, accountant, insurance agent, your security code(s) and company, your social security number, the location of your bills, your insurance information and policies, estate documents, your LivingForms, your safety deposit box and key as well as other essential materials.

• This LivingForm compiles all of this information in one place for easy access. Let one or more trusted family members or friends know where they can find this LivingForm in the event of an emergency or crisis.

• Having this information readily available will also be of great help to your heirs upon your death.

• This LivingForm includes two emergency information lists:
• One list is for the people you want to be informed in the event of an emergency or crisis.
• The second list adds the names and contact information of all those people you want to be notified in the event of your death.

23.  Personal Emergency Instructions and Authorization

• There are certain things that you will want others to take care of immediately in the event you are in involved in an emergency or crisis:
• a child or children to be care for;
• pets who need food, water, clean boxes or to be taken outside;
• elderly parents or other family members who depend on you to cook or shop for them, give medications, and other matters that need immediate attention.

These instructions/authorizations tell others what you want done and who you want to do it.

• Give copies of this LivingForm to everyone you name to undertake the various tasks you specify so they will know what they need to do immediately after being notified of your emergency or crisis.

• If you want to change any of your instructions or the people you want to undertake the tasks specified in the original Instructions and Authorization, use this LivingForm to revoke the Instructions and Authorizations and then create a new one with new instructions.

• Most of us have jobs and/or are affiliated with organizations that depend on us or would want to know if we were involved in an emergency or crisis.  This includes civic or non-profit organizations, your church, private club membership, etc. This form lets you provide the names of the organizations, a contact person if possible and contact information so that they can be readily reached if needed.

• If you are away from your home or apartment for more than a few days—whether due to an unexpected illness or injury or a planned trip—there are tasks that will need to be done to keep up your household until you are able to do it for yourself.

• Examples are picking up the mail at your home or a post office box, watering plants, putting out the trash, lawn care, snow removal, and other household matters.  This LivingForm will give others the instructions they need to maintain your home in your absence.

• This LivingForm allows you to keep a record of all the LivingForms currently in use and to whom you have given copies of those LivingForms.  This will prove helpful in the event you want to make changes and/or need to make one or more revocations for those LivingForms that you have shared with others.

• Many of us have items in our home that are very personal and private in nature that we wouldn’t want to be shared with friends or family members that may be in your home when we are hospitalized, recuperating in a rehab, assisted living or other facility or even deceased.  This LivingForm instructs a trusted friend or family member to take possession of any such articles under the circumstances specified in the Instructions and store or dispose of as instructed.

• It is a good idea to give someone written permission to be in your home when you aren’t there, whether they are just an occasional visitor or a frequent one like a pet sitter or dog walker.  You would be surprised how many alert neighbors will call the police if they see someone they don’t recognize entering or leaving your home when they know you aren’t there.

• If you change your mind about someone you have previously authorized to be in your home during your absence, sign this Revocation and send that person a copy of it so you are “on  record” as withdrawing your authorization.

31.  House Sitting Agreement

• This LivingForm is a “must” if you are going to have someone stay in your home while you are away for planned or unplanned absences… even if that person is a good friend or family member.

• This LivingForm must be signed by both yourself and the person staying in your home and provides detailed rights and responsibilities of both parties including:

• whether they are allowed visitors,
• how many, how often and under what circumstances,
• whether the sitter is allowed to use any automobile, hot tub or swimming pool,
• if the sitter is being paid and how much, etc.

The closer the friend or family member is to you, the more important it is to put things into writing and avoid possible misunderstandings that could affect your relationship.

• Should you become involved in an emergency or crisis and want someone to stay in your home to care for your children or pets, ask the person you want to stay in your home to sign this LivingForm with you.  Then give them a copy of it so they will be prepared to move into your home and undertake the responsibilities listed in the LivingForm once informed of your emergency.

• For planned absences which require a House Sitting Agreement, it is likely that you will choose a beginning and ending date for someone to stay in your home during your absence.  If you sign this LivingForm because you want someone to stay in your house during an emergency or crisis, you can choose, as you can with all LivingForms, to either stipulate that the LivingForm is only activated in the event of your illness or incapacitation OR it becomes valid upon signing and remains in effect unless revoked.  In the second instance, you will need to sign a Revocation if you want to make changes in the person or circumstances set forth in the original House Sitting Agreement.

• If you want someone else to be allowed to pick up your daily, certified or registered mail, packages
  OR have access to post office or other mail boxes or direct mail delivery, they must have your written authorization.

• Use this LivingForm to revoke the Authorization to Access Mail if you decide to withdraw your authorization.

• Passwords, user names, and other access codes are required more and more to access electronic devices, financial, on-line shopping, e-mails, and many other accounts.  With so much data to remember, it is easy to forget these passwords, user names and access codes, especially in connection with those things we use less frequently.  Use this LivingForm to record this information for easy reference.

• Because so many things are password protected today, if there were an emergency or crisis and it was important for someone to access any password-protected computers, voice mails, e-mail accounts, financial accounts, etc., they would be unable to do so unless they had the necessary information to access those accounts.  In the event of your death, your heirs would be in a real mess if they didn’t have access to this information.
   

Financial Matters
 

36.  List of All Loans, Mortgages and Other Non-Credit Card Loans

• Maintaining up-to-date information on your debts and other financial information should be a priority to better manage your finances.  This LivingForm makes it simple and easy.

• In order for others to assist you in an emergency or crisis, they need to know your financial obligations in the event you are unable to meet those obligations during this time.

• Without written authorization from you, lenders won’t even discuss your loans or mortgages, much less provide account details which will allow someone to help you in a time of emergency or crisis.  This form grants access to the person(s) you have chosen.

38.  Revocation of Authorization for Others to Access Loan Information and Accounts Under Certain
       Circumstances

• It is important to keep an up-to-date list of all of your credit card accounts, account numbers, and a telephone contact number.  This LivingForm makes it quick and easy to do.  In the event of the loss or theft of one or more of your credit cards, you will have the information you need to immediately notify the company to cancel the card(s).

• Additionally, if others are to assist you with your financial matters during an emergency or crisis, this information must be readily available.

• If you want to change any of your instructions or the people you want to undertake the tasks specified in the original Instructions and Authorization, use this LivingForm to revoke the Instructions and Authorizations and then create a new one with new instructions.

• If you are unable to make your credit card payments because of an illness, injury, or other circumstances and need someone to communicate with the credit card companies on your behalf, they must have your written authorization.

• If you change your mind about whom you want to have access to your credit card information, use this Revocation.

• Maintaining up-to-date financial records is a must for everyone and this LivingForm makes it quick and easy.

• If you are unable to take care of your financial matters yourself due to illness, injury, or other circumstances AND you want others to be able to assist you with those matters, you must make your important information immediately accessible to them.

• If you have an emergency or crisis and need assistance with financial matters, the person(s) you choose to help you must have your written authorization to work with your banks.

• This LivingForm even gives you the option of authorizing one or more people to become a signatory on one or more bank accounts so they can pay your bills or other items that you specify in the Authorization and under what circumstances.

• If you change your mind about whom you want to have access to your bank information or be a signatory on your account(s), use this LivingForm to revoke your authorization.

• In the event you become ill or injured and are unable to:
• make your own investment decisions,
• exercise any time sensitive options, or
• exercise other decisions in connection with your investments,

It is important that someone is authorized to oversee your investments for you.

• With this LivingForm, as with all others, you decide when this Authorization becomes effective, exactly what acts the authorized person can make on your behalf, and when the authorization expires.

• This LivingForm even allows you to decide if the authorized party can make trades on your behalf and under what circumstances.

• Change your mind about who you want to have access to your investment accounts or what they are authorized to do?  Use this Revocation and then sign a new authorization that reflects your current wishes.

• Use this Revocation if you decide that you no longer want to proceed with the act specified in the Power of Attorney; you’ve changed your mind about the person or persons you want to act on your behalf for the specified use, or any other reason.

 

Matters Relating to Pets

 

• Whether your pets are being cared for by others because of a planned absence or because of an emergency or crisis, they should have written authorization to allow them to seek medical attention on your behalf.

• Use this Revocation if you change your mind about who you want to be able to seek medical care for your pet(s).

• Detailed instructions for each pet includes any special dietary considerations, feeding instructions, exercise requirements, medication instructions, medical issues, the name of their vet, and more.

• Use these instructions for planned absences or in the event of an emergency or crisis so pet sitters, friends and family members can give your pets the care they deserve in your absence.  Be prepared for the unexpected and complete these instructions and give a copy to the person you want to care for your pets in an emergency so they are ready to help when needed.

• Don’t leave it up to someone else to decide who will care for your pets if you are unable to care for them yourself.  It is likely that you have a family member or friend who is not only close to your pets, but who has the time and willingness to undertake their care in an emergency or crisis.  Use this LivingForm to make certain the person you choose is the person who is there for your pets when you are unable to be there yourself.

• If you change your mind about whom you want to care for your pets in an emergency or crisis, revoke that authorization and IMMEDIATELY prepare a new Authorization to protect your pets.

• The person you have designated to care for your pets during an emergency or crisis may not be able or willing to care for them for a lengthy period of time (if your recuperation from an illness or injury requires a lengthy period of time).  Discuss this with the person you have chosen to care for your pets in an emergency or crisis and, if they aren’t able or willing to care for your pets over a long period of time, complete this LivingForm to have back-up provisions for your pets.

• If circumstances change and you change your mind about whom you want to care for your pets over a long period of time, use this Revocation and IMMEDIATELY prepare a new Authorization for long term care.

• One of the most important things you can do to show your pets that you love them is to make arrangements for their care in the event of your death.  Because death is frequently sudden, complete this LivingForm now to specify what you want to happen to each pet upon your death.  This LivingForm allows you to leave all your pets to one person or to make whatever arrangements you think best for their care after your death.

• This LivingForm includes detailed pet care instructions for each pet.

 

Small Business and Work Matters
 

• It doesn’t take long for a business to run off course, so make certain that you have someone lined up to help your business keep running if you have an emergency or crisis and are unable to manage your business yourself. 

• This LivingForm authorizes the person you specify to enter your place(s) of business (whether a home office or other location(s).

• You detail what functions they are to undertake to keep your business stable until you are able to assume management again yourself.

• Use this Revocation if circumstances change and you want to change the person(s) to act as your business “backup”.

59.  Work /Business Emergency Notification List

• Communication is the cornerstone of a successful business, so it is critical that you have instructions in place to notify clients, business associates, vendors and others if you have had an emergency or crisis and aren’t available to communicate with them.

• This LivingForm includes the name, affiliation and contact telephone number of everyone who should be notified in the event of emergency or crisis.

• If you are an employee rather than business owner, someone still needs to notify your employer, car pool, and other work-related persons in the event of an emergency or crisis.

• Financial organization is essential for a successful business and this LivingForm makes it quick and easy.

• If you become ill, injured or disabled for any period of time or even suddenly die, this information needs to be readily available for others to find.

• Keeping an up-to-date schedule of business-related debts should be a priority and this LivingForm allows you to do this quickly and easily.

• If you want someone to be able to help you in the event of an emergency or crisis, they will need immediate access to relevant financial information.  Keeping your debt information current will make any new loan application process much easier.

• If you want to make certain that your business bills continue to be paid or that someone at least communicates with your bank and lenders on your behalf in the event of an emergency or crisis, they will need written authorization from you.

• This LivingForm allows you to designate:
  
• who you want to have access to your banks and lenders,
• what they are allowed to do with the information,
• whether or not they have signature rights to the bank account(s),
• and which financial obligations they are authorized to pay from those accounts and under what circumstances.

• Use this LivingForm if you want to change either the person(s) you authorized to access your bank and loan accounts or what they are authorized to do with these accounts.

64.  Authorization to Access Business Computers, Phones, Message Centers, Passwords, Access Codes,
       Etc.

• If you are unable to manage your business because of hospitalization, illness, injury or any other circumstance, it is critical that the person you have chosen to look after your business is able to access your phone and e-mail messages, your computer and any other business tool that will give them information they need to keep your business running (until you are able to run it again yourself). 

• This LivingForm allows you to record the passwords, user names and other codes that go with each land line, cell phone, computer, e-mail account, financial and other accounts as well as any instructions needed to be able to access the information on these tools.

• Additionally, in the event of your death, access to your business information is critical to your heirs so they can file final tax returns, know which bills need to be paid or accounts that need to be collected.

• If you want to change who has access to your computers, etc., use this Revocation.

Matters Relating to Minor Children
 

• It is likely that, if a single parent has an emergency or crisis, that their minor children’s schedules will be interrupted for an unknown period of time.  This LivingForm provides the names and contact information of your children’s schools, day care, car pools, extracurricular activities and everyone else who needs to be notified if your children won’t be in attendance to those activities.  It also provides their temporary new contact information if they will be staying with friends or family during this time and much more.

• The primary concern of all single parents is that their children will be well cared for in the event they can’t care for them themselves.  This LivingForm identifies who you would like to assume responsibility for your children and it gives them the authority to undertake their care.

• As soon as you have completed this LivingForm, give a copy of it to the person(s) you want to care for your children in the event of an emergency or crisis so they will be immediately prepared to assume their care if the occasion arises.

68.  Revocation of Authorization to Care for Minor Children During Absence, Illness or Emergency

• Use this Revocation if you want to change who you want to care for your children in an emergency.  If you sent a copy of the original Authorization to the person you previously wanted to care for your children in an emergency, you should send them a copy of this Revocation after it has been completed.

• These instructions are comprehensive and include:
• your children’s individual dietary requirements,
• medications and medical information,
• name of doctors,
• their schools, bus and car pool information,
• after school and other activities,
• bed times,
• and other special instructions.

• If your children are under the care of others because of an emergency, crisis or other circumstance, it is essential that the person(s) caring for your children have written authority to seek and direct medical care for them in your absence.

• We recommend that you complete this LivingForm at the same time you complete the LivingForm Authorization to Care for Minor Children During Absence, Illness or Emergency.  Then immediately give a copy of both LivingForms to the person(s) you want to care for your children in an emergency so they will have the tools they need to immediately undertake their care, if necessary.

• We also recommend that you give your children’s doctors copies of the Medical Authorizations to keep in their files.

• Use this LivingForm if you no longer want the person specified in the original Authorization to care for your children in an emergency.  Send a copy of the Revocation to the person originally authorized to care for your children in an emergency if they have a copy of the Authorization.  You should also send a copy to your children’s doctors if you gave them a copy of the original Authorization.

• If you never gave anyone else a copy of the original authorization, then you can just destroy the original Authorization and you don’t need a Revocation.

• If you want those you have chosen to care for your children in an emergency or crisis, you need to give them access to the information they will need to properly care for your children while you are unable to do so yourself.

73.  Revocation of Authorization to Obtain Medical, Dental, Psychological, Psychiatric or Educational
       Records of a Minor

• Use this Revocation if you no longer want the person specified in the original Authorization to have access to your children’s records.

• Use this LivingForm for those occasions when you want your children to be able to travel WITHIN the United States with other family members, friend’s families, or others WITHOUT you.  A written authorization naming the adult responsible for your children’s care in your absence and where they are authorized to travel with your children is a must.

• This LivingForm is especially important when traveling by plane.

• Don’t forget to provide the adult responsible for your children while traveling with the LivingForm Authorization to Direct and Approve Medical Treatment/Care of a Minor so your children can get the medical care they may need when traveling.

• Use this Revocation if you want to withdraw approval for others to travel with your children within the United States.

• Use this LivingForm for those occasions when you want your children to be able to travel OUTSIDE the United States with other family members, friend’s families, or others WITHOUT you.  A written authorization naming the adult responsible for your children’s care in your absence and where they are authorized to travel with your children outside the United States is mandatory when traveling outside the country.

• Make certain that you give the adult responsible for your children while traveling outside the United States the LivingForm Authorization to Direct and Approve Medical Treatment/Care of a Minor so your children can get the medical care they may need if they are injured or become ill while out of the country.

77.  Revocation of Authorization to Travel with a Minor outside the United States

• Use this Revocation if you want to withdraw approval for others to travel with your children outside the United States.

Estate Matters
 

• No matter how small your estate, everyone has possessions that are particularly meaningful to them and that they want to go to the people in their life that will most appreciate them.  Use this LivingForm to list who you want your special possessions to go to upon your death.  Attach this LivingForm to your will after completion.

• This LivingForm can also be used to identify those personal possessions that are particularly valuable—though might not appear to be at first glance.  Unless you want to take the chance that these items might end up at a garage sale, use this LivingForm to specify which possessions are particularly valuable.

• This LivingForm allows you to send special messages or make final wishes known to those you leave behind but don’t want this information shared until after your death.  Attach this LivingForm to your will after completion.
   

PLEASE NOTE that Living Smart has provided a variety of Authorizations that address numerous topics. Living Smart not only believes that it is important not to overburden one person by expecting them to be responsible for overseeing all aspects of your life in the event of an emergency or longer term assistance, but that the person who is best qualified to take care of your pets and/or children and domestic responsibilities might not be the most qualified person to help with your personal finances or small business matters. Living Smart gives you the flexibility to select as many different people as you believe appropriate to lend a hand when you need help.

PLEASE CONSULT AN ATTORNEY FOR LEGAL ADVICE IF YOU HAVE ANY QUESTIONS ABOUT WHAT LIVINGFORMS ARE BEST SUITED FOR YOUR LIFE AND CIRCUMSTANCES.