Policy Manual sample

MDT Home Health Care Agency, Inc. STATEMENT OF WITNESSES This document must be witnessed by two qualified adult witnesses. None of the following may be used as a witness: · A person you designate as your Agent or Alternate Agent; · A healthcare provider; · An employee of a healthcare provider; · The operator of a community care facility; · An employee of an operator of a community care facility; · The operator of a residential care facility for the elderly; or · An employee of an operator of a residential care facility for the elderly. At least one of the witnesses must make the additional declaration set out following the place where the witnesses sign. (READ CAREFULLY BEFORE SIGNING. You can sign as a witness only if you personally know the Principal or the identity of the Principal, if proved to you by convincing evidence.) To have convincing evidence of the identity of the Principal, you must be presented with and reasonably rely on any one or more of the following: · An identification card or driver's license issued by the State Department of Motor Vehicles that is current or has been issued within five years. · A passport issued by the Department of State of the United Sates that is current or has been issued within five years. · Any of the following documents if the document is current or has been issued within five (5) years and contains a photograph and description of the person named on it, is signed by the person and bears a serial or other identifying number: · A passport issued by a foreign government that has been stamped by the United States Immigration and Naturalization Service; · A driver's license issued by a state other than ______________ or by a Canadian or Mexican public agency authorized to issue drivers' licenses; · An identification card issued by a state other than ______________; · An identification card issued by any branch of the Armed Forces of the United States. · If the Principal is a patient in a skilled nursing facility, a witness who is a Patient Advocate or Ombudsman may rely upon the representations of the Administrator or staff of the skilled nursing facility or of family members, as convincing evidence of the identity of the Principal if the Patient Advocate or Ombudsman believes that the representations provide a reasonable basis for determining the identity of the Principal. · Other kinds of proof of identity are not allowed. I declare under penalty of perjury under the laws of _______________, that the person who signed or acknowledged this document is personally known to me (or proved to me on the basis of convincing evidence) 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 healthcare provider, an employee of a healthcare provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care Home Health Agency Miscellaneous M-9