Acknowledgment of Advance Directive Policy

All patients have the right to participate in their own health care decisions and to make advance directives or to execute powers of attorney that authorize others to make decisions on their behalf based on the patient’s expressed wishes when the patient is unable to make decisions or unable to communicate decisions. Premier Eye Surgery Center respects and upholds those rights.

Because of the requirements of the Medical Treatment Act, we have developed a policy, that regardless of the contents of any Advance Directive or instructions from a health care surrogate or attorney in fact, if an adverse event occurs during your treatment at this facility, center staff will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation (“Policy”). At the acute care hospital further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, Advance Directive or Medical Durable Power of Attorney. Your signature below is your agreement to Premier Eye Surgery Center’s Policy and changes any Medical Durable Power of Attorney you may have to be the same as the Policy stated above for the current procedure or treatment to be performed on this visit to this surgery center.

Have you executed an Advance Health Care Directive, a Living Will, or a Health Care Power of Attorney, which authorizes someone to make health care decisions for you?

I DO/DO NOT have an Advance Directive or Health Care Power of Attorney.

(If a copy is provided, it will be made part of your medical record.)