This customizable document, Declaration - Exhibit K, is taken from MCN Healthcare’s Medical Office Policy and Procedure Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

Health care organizations around the world utilize MCN’s compliant ready templates and workflow process tools to help them meet the latest changes in regulations and standards.

Here is some sample content from Declaration - Exhibit K:

	EXHIBIT K DECLARATION If I should have an incurable and irreversible condition that has been diagnosed by two physicians and that will result in my death within a relatively short time without the administration of life-sustaining treatment or has produced an irreversible coma or persistent vegetative state, and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Natural Death Act of California, to withhold or withdraw treatment, including artificially administered nutrition and hydration, that only prolongs the process of...
Second excerpt:
	...this Signature: Address: The declarant voluntarily signed this writing in my presence. I am not a healthcare practitioner, an employee of a healthcare practitioner, the 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. Witness: Address: The declarant voluntarily signed this writing in my presence. I am not entitled to any portion of the estate of...