A GUIDE TO MEDICAL

AND LEGAL DECISIONS

Pl anning for You r
Pe ace of Mind

Revised 9/2021
Dear Friend,
This booklet was designed to assist you in pre-planning by providing frequently
asked questions and general information on MIPeace of Mind Registry, Funeral
Representative designation, Michigan's Statutory Will and Patient Advocate law, and
organ donation.
This booklet is not intended to replace the advice of legal professionals when it
comes to making long-term care and end-of-life decisions.
For additional information or if you are in need of a referral for legal counsel,
please contact:
State Bar of Michigan
Michael Franck Building
306 Townsend Street
Lansing, MI 48933-2012
Website: www.michbar.org
Phone: (517) 346-6300
Toll-free: (800) 968-1442
Fax: (517) 482-6248
Table of Contents
PERSONAL RECORDS......................................................................................................   3

MEDICAL AND PRESCRIPTION RECORDS.............................................................. 15

MICHIGAN STATUTORY WILL.................................................................................... 19

ADVANCE DIRECTIVES FOR HEALTH CARE:
    MICHIGAN’S PATIENT ADVOCATE LAW......................................................... 31

MIPEACE OF MIND REGISTRY................................................................................... 32

FUNERAL REPRESENTATIVE DESIGNATION........................................................... 35

GUIDE FOR USING THE DESIGNATION OF PATIENT ADVOCATE FORM..... 35

ORGAN DONATION......................................................................................................... 45

Prepared by the Michigan Legislature

This information is provided free to Michigan citizens

and is not for reproduction for resale or profit.

(Revised 9/2021)
Personal Records

3
 PERSONAL RECORDS
OF

________________________
(Your full legal name)

A RESIDENT OF THE
STATE OF MICHIGAN

Address____________________________________________________________________________________

____________________________________________________________________________________________________

Telephone number____________________________________________________________________________

Date completed______________________________________________________________________________

4
YOUR WILL
Do you have a Will? n Yes n No If yes, where is it kept?______________________________________

__________________________________________________________________________________________

Name and address of personal representative___________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Name and address of Attorney/Law Firm if you use one_________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Date of most recent Will_______________________________________________________________________

The date is important. You should review your Will if there are any changes in circumstances such
as marriage; divorce; change in assets; birth or adoption of children since the will was signed; death
of any beneficiaries; changes in state or federal law; change of residence; unavailability of witnesses;
or death, age, or failing powers of the person named as personal representative.
REMEMBER: If you do not have a Will, your estate will be distributed as provided by state law.
Its formula for distribution may not be the same as you would want. Your wishes and your family’s
special needs can best be satisfied if you make a Will.

REAL ESTATE
Do you own real estate (for instance, a home, land or other)? n Yes n No
If yes, provide the following information:
Real Estate #1 __________________________________________________________________________
(Real estate name and location)

List names and addresses on the title for this real estate_______________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Is there a mortgage on the property? n Yes n No

If yes, mortgage company name______________________________________________________________

5
Real Estate #1 (Continued)
List names on the mortgage______________________________________________________________

The deed, a copy of the mortgage, survey, title insurance policy, and closing documents are

kept_____________________________________________________________________________________

Real estate tax receipts are kept_______________________________________________________________

Insurance policies, like fire and liability, are kept____________________________________________

____________________________________________________________________________________

For advice as to keeping or selling the property, consult________________________________________

whose contact information is_____________________________________________________________

_______________________________________________________________________________________

Real Estate #2 ___________________________________________________________________________

(Real estate name and location)

List names and addresses on the title for this real estate_______________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Is there a mortgage on the property? n Yes n No

If yes, mortgage company name______________________________________________________________

List names on the mortgage______________________________________________________________

The deed, a copy of the mortgage, survey, title insurance policy, and closing documents are

kept_____________________________________________________________________________________

Real estate tax receipts are kept_______________________________________________________________

Insurance policies, like fire and liability, are kept_______________________________________________

____________________________________________________________________________________

For advice as to keeping or selling the property, consult________________________________________

whose contact information is_____________________________________________________________

____________________________________________________________________________________

6
Real Estate #3___________________________________________________________________________
(Real estate name and location)

List names and addresses on the title for this real estate_______________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Is there a mortgage on the property? n Yes n No

If yes, mortgage company name______________________________________________________________

List names on the mortgage______________________________________________________________

The deed, a copy of the mortgage, survey, title insurance policy, and closing documents are

kept______________________________________________________________________________________

Real estate tax receipts are kept_______________________________________________________________

Insurance policies, like fire and liability, are kept_______________________________________________

____________________________________________________________________________________

For advice as to keeping or selling the property, consult________________________________________

whose contact information is_____________________________________________________________

____________________________________________________________________________________

Additional Notes

7
LIFE INSURANCE
Do you have life insurance? n Yes n No

If yes, company name and policy number_____________________________________________________

_______________________________________________________________________________________

Is the life insurance in trust? n Yes n No

If yes, list the trustee name and contact information______________________________________________

_______________________________________________________________________________________

List beneficiary(ies) of this policy(ies)__________________________________________________________

Policy(ies) are kept____________________________________________________________________________

Are there any unpaid loans secured by this policy(ies)? n Yes n No

If yes, list lender contact information____________________________________________________________

Name of your insurance advisor_________________________________________________________________

Insurance advisor contact information________________________________________________________

_______________________________________________________________________________________

MILITARY, FRATERNAL, OR COMPANY INSURANCE

Do you have military, fraternal, or company insurance? n Yes n No

If yes, company name and policy number_____________________________________________________

_______________________________________________________________________________________

Is the life insurance in trust? n Yes n No

If yes, list the trustee name and contact information______________________________________________

_______________________________________________________________________________________

List beneficiary(ies) of this policy(ies)__________________________________________________________

Policy(ies) are kept____________________________________________________________________________

Are there any unpaid loans secured by this policy(ies)? n Yes n No

If yes, list lender contact information____________________________________________________________

Name of your insurance advisor_________________________________________________________________

Insurance advisor contact information________________________________________________________

_______________________________________________________________________________________

8
OTHER PERSONAL INSURANCE
Do you have health and accident insurance? n Yes n No

If yes, company name and policy number_____________________________________________________

_______________________________________________________________________________________

Do you have hospitalization insurance? n Yes n No

If yes, company name and policy number_____________________________________________________

_______________________________________________________________________________________

Do you have insurance for medical and surgical expenses? n Yes n No

If yes, company name and policy number_____________________________________________________

_______________________________________________________________________________________

Policies are kept_______________________________________________________________________________

SOCIAL SECURITY
Social Security Number______________________________________________________________________

Card is kept_________________________________________________________________________________

Employment record is kept______________________________________________________________________

PENSION AND RETIREMENT INFORMATION

Do you have a pension or other retirement program? n Yes n No

If yes, company name and policy number_____________________________________________________

_______________________________________________________________________________________

Is there a survivor benefit? n Yes n No

List beneficiary(ies) of this policy(ies)__________________________________________________________

Address___________________________________________________________________________________

_______________________________________________________________________________________

9
FAMILY RECORDS
List your birthplace _________________________________________________________________________
(Hospital name, city, state)

Your birth date_________________________________________________________________________________

Are you married? n Yes n No

If yes, list the date, city and state of the marriage_________________________________________________

__________________________________________________________________________________________

Where are other important family documents, such as birth certificates (or other proof of dates of
birth) of family members, marriage certificates, judgments of divorce, death certificates, naturalization
papers, military service and discharge papers and any other family documents kept?

__________________________________________________________________________________________

BANK RECORDSLIST CHECKING ACCOUNT(S) HERE

Name(s) on this Account (include co-owner names) Name(s) on this Account (include co-owner names)

Bank Name Bank Name

Address Address

Telephone Telephone
Account No. Account No.
Beneficiary Beneficiary

LIST SAVINGS ACCOUNT(S) HERE

Name(s) on this Account (include co-owner names) Name(s) on this Account (include co-owner names)

Bank Name Bank Name

Address Address

Telephone Telephone
Account No. Account No.
Beneficiary Beneficiary

10
 LIST CERTIFICATES OF DEPOSIT (CDs) HERE

Name(s) on this Account (include co-owner names) Name(s) on this Account (include co-owner names)

Bank Name Bank Name

Address Address

Telephone Telephone
Account No. Account No.
Beneficiary Beneficiary

Where do you keep bank books, canceled checks, and statements?_______________________________

__________________________________________________________________________________________

LIST IRA ACCOUNTS HERE

Name(s) on this Account (include co-owner names) Name(s) on this Account (include co-owner names)

Bank Name Bank Name

Address Address

Telephone Telephone
Account No. Account No.
Beneficiary Beneficiary

LIST SAFE DEPOSIT BOX INFORMATION HERE

Name(s) on this Account (include co-owner names) Name(s) on this Account (include co-owner names)

Bank Name Bank Name

Address Address

Telephone Telephone
Key is kept Key is kept

Where are additional checking, savings, certificate of deposit information kept?_____________________

__________________________________________________________________________________________

11
 LIST U.S. SAVINGS BONDS HERE

Name(s) registered in Name(s) registered in

Bonds can be found Bonds can be found

Beneficiary or co-owner Beneficiary or co-owner

Name(s) registered in Name(s) registered in

Bonds can be found Bonds can be found

Beneficiary or co-owner Beneficiary or co-owner

A list of all bonds by serial number and denomination is kept______________________________________

__________________________________________________________________________________________

LIST OTHER BONDS PREFERRED OR CORPORATE STOCKS HERE

Name of Sole Owner Name of Joint Owner

Bonds/Stocks kept Bonds/Stocks kept

Broker Broker
Broker Address Broker Address

List and records of purchases are kept List and records of purchases are kept

*LIST OTHER PERSONAL PROPERTY INFORMATION HERE

Name(s) on title of your motor vehicle(s)

Vehicle title and insurance policy(ies) are kept

Are household furnishings insured? n Yes n No If yes, where is policy kept?

Policies, inventory, and bills of sale are kept

*Attach additional bond, stock, personal property information

12
FUNERAL ARRANGEMENTS
Do you own a cemetery plot? n Yes n No

If yes, where is the deed kept?_________________________________________________________________

Do you have a pre-paid funeral? n Yes n No

If yes, list the name of the funeral home and where the receipt is kept_____________________________

________________________________________________________________________________________

IF YOU ARE SELF-EMPLOYED

The business name and address_______________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

What is the corporate structure of the business?_________________________________________________

__________________________________________________________________________________________

Where are copies of business agreements and other related documents located?_____________________

__________________________________________________________________________________________

For advice as to handling or disposition of this business, consult__________________________________

Address and other contact information_____________________________________________________

________________________________________________________________________________________

IF YOU ARE NOT SELF-EMPLOYED

Your employer and employer contact information________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________

Name and phone number of noted emergency contact_____________________________________________

__________________________________________________________________________________

13
OTHER MATTERS
List all personal creditors or debtors here__________________________________________________________

__________________________________________________________________________________________

Copies of notes, loan agreements, and receipts are kept___________________________________________

Income tax records and supporting data are kept__________________________________________________

Credit card records are kept_____________________________________________________________________ 

A list of the accounts that have a death benefit payoff is kept_______________________________________

__________________________________________________________________________________________

Your tax advisor’s name and contact information__________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

LIST HEIRS (Example: Spouse, Children, Other Relative),

DEVISEES, AND BENEFICIARIES TO INHERIT PROPERTY UNDER YOUR WILL
Name Date of Birth Relationship Address

Are any of the above under legal disability or otherwise represented by a guardian or conservator?

Name Legal Disability Represented by: Name and Address

14
 Medical and
Prescription Records

15
MEDICAL INFORMATION
List all allergies and drug sensitivities here____________________________________________________

__________________________________________________________________________________________

Blood type____________________________________________________________________________________

Medical conditions______________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

LIST YOUR HEALTH CARE PROVIDERS

Doctor Name Doctor Name Doctor Name

Specialty Specialty Specialty

Address Address Address

Phone Phone Phone

Name of Preferred Hospital

Address Phone

Name of Preferred Pharmacy

Address Phone

Dentist Name

Address Phone

Optometrist Name

Address Phone

16
 LIST ALL MEDICATIONS YOU CURRENTLY TAKE

#1 Name of Drug #2 Name of Drug #3 Name of Drug

Date Prescribed Date Prescribed Date Prescribed

Doctor’s Name Doctor’s Name Doctor’s Name

Prescribed for What? Prescribed for What? Prescribed for What?

Color/Shape/Strength Color/Shape/Strength Color/Shape/Strength

Directions/Cautions Directions/Cautions Directions/Cautions

Kept Kept Kept

#4 Name of Drug #5 Name of Drug #6 Name of Drug

Date Prescribed Date Prescribed Date Prescribed

Doctor’s Name Doctor’s Name Doctor’s Name

Prescribed for What? Prescribed for What? Prescribed for What?

Color/Shape/Strength Color/Shape/Strength Color/Shape/Strength

Directions/Cautions Directions/Cautions Directions/Cautions

Kept Kept Kept

17
 LIST ALL MEDICATIONS YOU CURRENTLY TAKE

#7 Name of Drug #8 Name of Drug #9 Name of Drug

Date Prescribed Date Prescribed Date Prescribed

Doctor’s Name Doctor’s Name Doctor’s Name

Prescribed for What? Prescribed for What? Prescribed for What?

Color/Shape/Strength Color/Shape/Strength Color/Shape/Strength

Directions/Cautions Directions/Cautions Directions/Cautions

Kept Kept Kept

#10 Name of Drug #11 Name of Drug #12 Name of Drug

Date Prescribed Date Prescribed Date Prescribed

Doctor’s Name Doctor’s Name Doctor’s Name

Prescribed for What? Prescribed for What? Prescribed for What?

Color/Shape/Strength Color/Shape/Strength Color/Shape/Strength

Directions/Cautions Directions/Cautions Directions/Cautions

Kept Kept Kept

18
 Michigan
Statutory Will

19
Frequently Asked Questions
1.  What happens if I die without a Will?
With certain exceptions, your possessions are distributed according to state law.

2.  What can I accomplish by making out a Will?

You can choose who is to receive your property; select someone to serve as personal representative
(formerly known as executor); and appoint a guardian and conservator for your children under
age 18.

3.  Does having a Will avoid probate procedures after my death?

No. The issue of whether probate procedures must be followed is not solely dependent on whether
or not you have a Will.

4.  What property is not subject to probate procedures?

Property such as money held in a joint bank account; real estate, if your spouse’s name or a joint
tenant’s name is on the deed; life insurance benefits, if a person living at the time of your death
was named as a beneficiary in the policy; and some other assets that are jointly held or have
beneficiary designations.

5. If property is specified in my Will, am I prevented from giving it away or selling it during
my life?
No. Your Will has absolutely no effect until you die. If you sell or give away property mentioned
in the Will, that provision of the Will is simply ignored.

6.  Are there different types of Wills?

Yes. Each type is equally valid if done precisely in accordance with the law. It is recommended that
you see an attorney if you do not want to use the Statutory Will form provided in this booklet.

7.  What are some of the things I can accomplish through a Statutory Will?
(a)  You can leave up to two cash gifts of any amount to people or charities.
(b) You can write a list of personal and household items and name the person or entity to receive
each item.
(c) You can ensure that the rest of your property goes to your spouse. If he or she dies before you,
the property is to be distributed equally among your children.
(d)  You can select a personal representative to administer your property.
(e) You can appoint a guardian and conservator in case you and your spouse both die before your
children reach age 18.

8. Are there any reasons for me NOT to use the Statutory Will form provided in this brochure?
There may be. If, for instance, you have substantial wealth and need tax planning for your estate,
you should consult an attorney who handles estate planning to discuss your specific needs.
Consultation with an attorney is strongly recommended if you want to establish a trust fund for
your children’s education, if you have assets outside the State of Michigan, if you have children
from a prior relationship, or if you have a significant interest in a business or partnership.

20
  9. I have a wife and two young children. Might a Statutory Will be appropriate for my purposes?
Perhaps. A Statutory Will might be appropriate if you do not have extensive assets and, therefore,
do not need tax planning. In a Statutory Will, you can appoint a guardian for your children and a
conservator for your children’s assets.

10. I would like to leave my favorite niece an antique brooch. Can I do this with a Statutory Will?
Yes. A Statutory Will allows you to leave gifts of personal items by making a list of the items and
the names of the persons you want to receive each item.

11. I am a widow with no children. Could a Statutory Will be appropriate for me?
If you do not have substantial assets and you do not object to the limited options for disposing of
your property, you may want to use the Statutory Will form.

12. I own a house, a condominium, and much stock. Should I use a Statutory Will?
Perhaps not. A Statutory Will is not designed to reduce federal or state taxes on your estate.
If you have very substantial assets, you may wish to check with an attorney to see if tax planning
is recommended.

13. I am married for the second time and my husband and I each have children from our first
marriages. Would a Statutory Will be appropriate for my purposes?
Probably not. The Statutory Will provides that your estate goes to your husband if he survives
you. For that reason, the Statutory Will may not give you an adequate way to provide for the
children from your first marriage. Speaking with an attorney is likely a good idea for a person
with children from a previous relationship.

14. I have rather complicated business interests, which I wish to pass on through my Will.
Would a Statutory Will be appropriate for my purposes?
No. A Statutory Will does not provide for any specific business planning.

15. What should I do if a Statutory Will doesn’t meet my needs?

Contact an attorney with knowledge of estate planning. He or she can draft a Will to meet your
specific needs.

16. How can I find a good attorney?

(a) If you have dealt with an attorney in the past and were satisfied, contact that person.
An attorney who does not handle estate planning may recommend someone who does.
(b) Ask friends, neighbors, or relatives.
(c) Ask a person you respect, such as a religious leader, or call an organization such as a
consumer group or a civic organization.
(d) Call the county or state bar referral service, which will provide you with the names of
attorneys.
(e) Consult the business section of your telephone directory or newspaper classified section.
Don’t be intimidated. Don’t be afraid to “shop around” for someone you are comfortable with
and whose services you can afford.

21
17.  How do I use the Statutory Will form?
First, thoroughly read the entire form. Read the notice at the beginning and the definitions at the
end. After you are sure you understand all of the Will’s provisions, carefully follow the directions
and fill in the blanks.

18.  Can a Statutory Will be a joint Will?

No. A husband and wife cannot both use a single Statutory Will. If one spouse chooses to use
a Statutory Will, the other spouse is free to complete a separate Statutory Will or to choose a
different type of Will.

19.  May I use a Statutory Will form and yet leave no cash gifts? (Article 2.1)
Yes. You may leave no cash gifts, one cash gift, or two cash gifts. If you do leave a cash gift, it is
particularly important that you give a complete address of the person or charity to receive the
money.

20.  How do I go about preparing a list of personal items? (Article 2.2)

List the possessions such as jewelry, books, automobiles, furniture, and other personal and
household items on a separate piece of paper. On the list, name the person who is to receive each
item. The list can be as short or long as you choose. Make sure you describe each item sufficiently
to avoid confusion. For each person who is to receive an item, include his or her full name and
address. The list must be in your handwriting or signed by you at the end. It is a very good idea
to include the date. You may make the list before you complete the Statutory Will form, at the
same time, or afterward. You can change the list as often as you wish. It is a good idea to staple
or firmly attach the newest list to your Will.

21.  What is the purpose of Article 2.3?

This provision sets out the distribution of your property (other than cash gifts and the list of
items) if you have no living spouse, children, grandchildren, and great-grandchildren. You have a
choice: you may leave all the property to your blood relatives who survive you, or leave one-half
to those relatives and one-half to your deceased spouse’s blood relatives. Make your choice by
signing your name under the appropriate paragraph.

22.  Need I complete Article 3.2 if all of my children are over 18?
No. You may skip Article 3.2 relating to guardians and conservators.

23. How do I decide whether to have my Personal Representative serve with or without bond?
(Article 3.3)
Most people request that the Personal Representative serve without bond. If you are careful to
choose a person you trust to be Personal Representative, you may wish that no money be spent
for a bond.

24.  After the Will is completed, where should I keep it?

One option is to file it in probate court in the county you live in; such filings cost very little.
Wherever you keep the Will, it is a good idea to attach the list of personal items to the Will. You
may want to give a copy of the Will to the person you have selected as Personal Representative. If
you file the Will with a court, you should file a new copy any time you make a change.

22
25.  Can I make changes to my Statutory Will?
Yes. Since a Will has absolutely no effect until you die, you can change the Will as often as you
desire during your lifetime. But do not make corrections on the Will. You can either complete a
new Statutory Will, or have a codicil (an amendment to the old Will) or have an entirely new Will
drafted by an attorney. If you sign a new Will, destroy copies of the old one. You can change the
list of personal property items at any time. Make sure to attach the most recent list to your Will. It
is probably best to write a whole new list if you decide to make changes.

26.  If I move from Michigan, would my Statutory Will still be valid?

Probably yes. It would be a good idea to check with an attorney who practices law in the state of
your new residence.

27.  Does my Statutory Will need to be notarized?

No, but it does need to be witnessed.

23
MICHIGAN STATUTORY WILL
NOTICE

1.  An individual age 18 or older and who has sufficient mental capacity may make a Will.

2.  There are several kinds of wills. If you choose to complete this form, you will have a Michigan
Statutory Will. If this Will does not meet your wishes in any way, you should talk with an attorney
before choosing a Michigan Statutory Will.

3.  Warning! It is strongly recommended that you do not add or cross out any words on this form
except for filling in the blanks because all or part of this Will may not be valid if you do so.

4.  This Will has no effect on jointly held assets, on retirement plan benefits, or on life insurance on
your life if you have named a beneficiary and the beneficiary survives you.

5.  This Will is not designed to reduce estate taxes.

6.  
This Will treats adopted children and children born outside of wedlock who would inherit if their
parent died without a Will the same way as children born or conceived during marriage.

7. You should keep this Will in your safe deposit box or other safe place. By paying a small fee,
you may file this Will in your county’s probate court for safekeeping. You should also tell your
family where the Will is kept. If you do not designate another individual to have access to your
safe deposit box, your family may need to obtain a county probate court order to open your safe
deposit box to access your Will.

8. You may make and sign a new Will at any time. If you marry or divorce after you sign this Will,
you should make and sign a new Will.

INSTRUCTIONS

1.  To have a Michigan Statutory Will, you must complete the blanks on the will form. You may do
this yourself, or direct someone to do it for you. You must either sign the will or direct someone
else to sign it in your name and in your presence.

2.  Read the entire Michigan Statutory Will carefully before you begin filling in the blanks. If there is
anything you do not understand, you should ask an attorney to explain it to you.

24
 Michigan Statutory Will
of
__________________________________________________________________________________________
(Print or type your full name)

Article 1. Declarations
This is my Will and I revoke any prior Wills and codicils. I live in

_________________________________________ County, Michigan.

My spouse is______________________________________________________________________________ .
(Insert spouse’s name or write “none”)

My children now living are:

__________________________________________ _____________________________________________

__________________________________________ _____________________________________________

__________________________________________ _____________________________________________
(Insert names or write “none”)

Article 2. Disposition of My Assets

2.1 CASH GIFTS TO PERSONS OR CHARITIES. (Optional)
I can leave no more than two (2) cash gifts. I make the following cash gifts to the persons or
charities in the amounts stated here. Any transfer tax due upon my death shall be paid from the
balance of my estate and not from these gifts.

Full name and address of person or charity to receive cash gift

(Name only 1 person or charity here):

__________________________________________________________________________________________
(Insert name of person or charity)

__________________________________________________________________________________________
(Insert address)

AMOUNT OF GIFT (In figures): $____________________________________________________________

AMOUNT OF GIFT (In words): _____________________________________________________Dollars

___________________________________________________________
(Your signature)

25
Full name and address of person or charity to receive cash gift
(Name only 1 person or charity here) :

__________________________________________________________________________________________
(Insert name of person or charity)

__________________________________________________________________________________________
(Insert address)

AMOUNT OF GIFT (In figures): $____________________________________________________________

AMOUNT OF GIFT (In words): _____________________________________________________Dollars

___________________________________________________________
(Your signature)

2.2 PERSONAL AND HOUSEHOLD ITEMS.

I may leave a separate list or statement, either in my handwriting or signed by me at the end,
regarding gifts of specific books, jewelry, clothing, automobiles, furniture, and other personal and
household items.
I give my spouse all my books, jewelry, clothing, automobiles, furniture, and other personal and
household items not included on such a separate list or statement. If I am not married at the time
I sign this Will or if my spouse dies before me, my Personal Representative shall distribute those
items, as equally as possible, among my children who survive me. If no children survive me, these
items shall be distributed as set forth in paragraph 2.3.

2.3 ALL OTHER ASSETS.

I give everything else I own to my spouse. If I am not married at the time I sign this Will or if my
spouse dies before me, I give these assets to my children and the descendants of any deceased child.
If no spouse, children, or descendants of children survive me, I choose 1 of the following distribution
clauses by signing my name on the line after that clause. If I sign on both lines, if I fail to sign on
either line, or if I am not married, these assets will go under distribution clause (b).
Distribution clause, if no spouse, children, or descendants of children survive me, then
(Select only 1)
(a) One-half is to be distributed to my heirs as if I did not have a Will, and one-half is to be
distributed to my deceased spouse’s heirs as if my spouse had died just after me without a Will.

___________________________________________________________
(Your signature)

(b) All is to be distributed to my heirs as if I did not have a Will.

___________________________________________________________
(Your signature)

26
Article 3. Nominations of Personal Representative,
Guardian, and Conservator
Personal representatives, guardians, and conservators have a great deal of responsibility. The
role of a personal representative is to collect and protect your assets, pay debts and taxes from those
assets, and distribute the remaining assets as directed in the Will. A guardian is a person who will
look after the physical well-being of a child. A conservator is a person who will manage a child’s
assets and make payments from those assets for the child’s benefit. Select them carefully. Also, before
you select them, ask them whether they are willing and able to serve.

3.1 PERSONAL REPRESENTATIVE. (Name at least 1)

I nominate ____________________________________________________________________________________
(Insert name of person or eligible financial institution)

of ___________________________________________________________________________________________
(Insert address)
to serve as my personal representative.

If my first choice does not serve, I nominate ____________________________________________________

(Insert name of person or eligible financial institution)

of ___________________________________________________________________________________________
(Insert address)
to serve as my personal representative.

3.2 GUARDIAN AND CONSERVATOR.

Your spouse may die before you. Therefore, if you have a child under age 18, you should name an
individual as guardian of the child, and an individual or eligible financial institution as conservator
of the child’s assets. The guardian and the conservator may, but need not be, the same person.

If a guardian or conservator is needed for a child of mine, I nominate

__________________________________________________________________________________________
(Insert name of individual)

of _______________________________________________________________________________ as guardian
(Insert address)

and ______________________________________________________________________________________________
(Insert name of individual or eligible financial institution)

of ______________________________________________________________________________________________
(Insert address)
to serve as conservator.

27
If my first choice cannot serve, I nominate _______________________________________________________
(Insert name of individual)

of _______________________________________________________________________________ as guardian
(Insert address)

and ______________________________________________________________________________________________________
(Insert name of individual or eligible financial institution)

of ______________________________________________________________________ to serve as conservator.

(Insert address)

3.3 BOND.

A bond is a form of insurance in case your personal representative or a conservator performs

improperly and jeopardizes your assets. A bond is not required. You may choose whether you wish
to require your personal representative and any conservator to serve with or without bond. Bond
premiums would be paid out of your assets. (Select only 1)

(a) My personal representative and any conservator I have named shall serve with bond.

___________________________________________________________
(Your signature)

(b) My personal representative and any conservator I have named shall serve without bond.

___________________________________________________________
(Your signature)

3.4 DEFINITIONS AND ADDITIONAL CLAUSES.

Definitions and additional clauses found at the end of this form are part of this will.

I sign my name to this Michigan Statutory Will on  __________________________ , 20_______ .

___________________________________________________________
(Your signature)

28
NOTICE REGARDING WITNESSES
You must use 2 adults as witnesses. It is preferable to have 3 adult witnesses. All the witnesses
must observe you sign the Will, have you tell them you signed the Will, or have you tell them the
Will was signed at your direction in your presence.

STATEMENT OF WITNESSES
We sign below as witnesses, declaring that the individual who is making this Will appears to have
sufficient mental capacity to make this Will and appears to be making this Will freely, without duress,
fraud, or undue influence, and that the individual making this Will acknowledges that he or she has
read the Will, or has had it read to him or her, and understands the contents of this Will.

_____________________________________________
(Print name)

_____________________________________________
(Signature of witness)

_____________________________________________
(Address)

____________________________ _______ ___________

(City) (State) (Zip)

_____________________________________________
(Print name)

_____________________________________________
(Signature of witness)

_____________________________________________
(Address)

____________________________ _______ ___________

(City) (State) (Zip)

_____________________________________________
(Print name)

_____________________________________________
(Signature of witness)

_____________________________________________
(Address)

____________________________ _______ ___________

(City) (State) (Zip)

29
Definitions
The following definitions and rules of construction apply to this Michigan Statutory Will:
(a) “Assets” means all types of property you can own, such as real estate, stocks and bonds, bank
accounts, business interests, furniture, and automobiles.
(b) “Descendants” means your children, grandchildren, and their descendants.
(c) “Descendants” or “children” includes individuals born or conceived during marriage, individuals
legally adopted, and individuals born out of wedlock who would inherit if their parent died
without a will.
(d) “Jointly held assets” means those assets to which ownership is transferred automatically upon the
death of 1 of the owners to the remaining owner or owners.
(e) “Spouse” means your husband or wife at the time you sign this Will.
(f) Whenever a distribution under a Michigan Statutory Will is to be made to an individual’s
descendants, the assets are to be divided into as many equal shares as there are then living
descendants of the nearest degree of living descendants and deceased descendants of that same
degree who leave living descendants. Each living descendant of the nearest degree shall receive
1 share. The remaining shares, if any, are combined and then divided in the same manner among
the surviving descendants of the deceased descendants as if the surviving descendants who
were allocated a share and their surviving descendants had predeceased the descendant. In this
manner, all descendants who are in the same generation will take an equal share.
(g) “Heirs” means those persons who would have received your assets if you had died without a
will, domiciled in Michigan, under the laws that are then in effect.
(h) “Person” includes individuals and institutions.
(i) Plural and singular words include each other, where appropriate.
(j) If a Michigan Statutory Will states that a person shall perform an act, the person is required to
perform that act. If a Michigan Statutory Will states that a person may do an act, the person’s
decision to do or not to do the act shall be made in good faith exercise of the person’s powers. 

Additional Clauses
Powers of personal representative.
(1) A personal representative has all powers of administration given by Michigan law to personal
representatives and, to the extent funds are not needed to meet debts and expenses currently
payable and are not immediately distributable, the power to invest and reinvest the estate from
time to time in accordance with the Michigan prudent investor rule. In dividing and distributing
the estate, the personal representative may distribute partially or totally in kind, may determine
the value of distributions in kind without reference to income tax bases, and may make
non-pro rata distributions.
(2) The personal representative may distribute estate assets otherwise distributable to a minor
beneficiary to the minor’s conservator or, in amounts not exceeding $5,000.00 per year, either to
the minor, if married; to a parent or another adult with whom the minor resides and who has the
care, custody, or control of the minor; or to the guardian. The personal representative is free of
liability and is discharged from further accountability for distributing assets in compliance with
the provisions of this paragraph.
Powers of guardian and conservator.
A guardian named in this Will has the same authority with respect to the child as a parent having
legal custody would have. A conservator named in this Will has all of the powers conferred by law. 

30
Advance Directives
for Health Care:
michigan’s patient
advocate law

31
Frequently Asked Questions
1. What is an “advance directive”?
An advance directive is a written document in which a competent individual gives instructions
about his or her health care, that will be implemented at some future time should that person lack
the ability to make decisions for himself or herself.
2.  Must I have an advance directive?
No. The decision to have an advance directive is purely voluntary. No family member, hospital,
or insurance company can force you to have one, or dictate what the document should say if you
decide to write one.
3.  Are there different types of advance directives?
Yes. There are three types: a durable power of attorney for health care, a living will, and a
do-not-resuscitate order. Living wills are not recognized in Michigan statute. However, in case
of a dispute as to your health care desires, your written or oral statements regarding your wishes
pertaining to health care or the withdrawal or refusal of treatment may be used as evidence
in court, if you are unable to participate in health care decisions. You may wish to consult an
attorney for further information regarding durable powers of attorney or living wills.
4. What is MIPeace of Mind Registry?
The Michigan Peace of Mind Registry is a free and voluntary statewide registry service that
securely stores your advance directive and allows healthcare providers to access it, if or when
needed. MIPeace of Mind will provide you with a wallet-sized registration card you can present
to a healthcare provider so they may request a copy of your advance directive. Registration does
not affect whether your advance directive is legally binding. For more information please contact
Gift of Life Michigan, (800) 482-4881, www.MIPeaceofMind.org.
5.  What is a “designation of patient advocate”?
In Michigan statute, a designation of patient advocate is the term used for a durable power of
attorney for health care, also known as a health care proxy—a document in which you give
another person the power to make medical treatment and related personal care and custody
decisions for you.
6. Is a durable power of attorney for health and/or mental health care legally binding in Michigan?
Yes, based on a state law passed in 1990 (PA 312 of 1990), later replaced by PA 386 of 1998 and
PA 532 of 2004 (sections 700.5506-700.5515 of the Michigan Compiled Laws).
7.  Who is eligible to create a designation of patient advocate?
Anyone who is 18 years of age or older and of sound mind is eligible.
8.  What is the title of the person to whom I give decision-making power?
That person is known as a “patient advocate.”
9.  Who may I appoint as a patient advocate?
Anyone who is 18 years of age or older may be appointed. You should choose someone you trust
who can handle the responsibility and who is willing to serve.
10.  Does a patient advocate need to accept the responsibility before acting?
Yes, he or she must sign an acceptance. This does not have to be done at the time you sign
the document. Nevertheless, you should speak to the person you propose to name as patient
advocate to make sure he or she is willing to serve.

32
11.  When can the patient advocate act in my behalf?
The patient advocate can make decisions for you only when you are unable to participate in
medical treatment decisions. The patient advocate for mental health treatment can make decisions
for you when you are unable to give informed consent for mental health treatment.

12.  Why might I be unable to participate in medical and mental health treatment decisions?
You may become temporarily or permanently unconscious from disease, accident, or surgery.
You may be awake but mentally unable to make decisions about your care due to disease
or injury. In addition, you might have a temporary loss of ability to make or communicate
decisions if, for example, you had a stroke. Others might suffer long-term or permanent loss
through a degenerative condition such as Alzheimer’s disease. Your doctor and a mental health
professional, after examination, may determine that you are unable to give informed consent for
mental health treatment.

13.  Who determines that I am no longer able to participate in these decisions?

Your attending physician and one other physician or licensed psychologist must make that
determination. If your religious beliefs prohibit an examination to make this determination,
and this is stated in the designation document, you must indicate in the document how the
determination will be made. For mental health treatment, your physician and a mental health
professional must make that determination.

14.  What powers can I give a patient advocate?

You can give a patient advocate the power to make those personal care decisions you normally
make for yourself. For example, you can give your patient advocate power to consent to or refuse
medical treatment for you, to arrange for home health care or adult day care, arrange care in a
nursing home, or move you to a home for the aged. A patient advocate may also be e­ mpowered
to make an anatomical gift of all or part of the patient’s body. According to state law, if you were
to become incompetent while pregnant, your patient advocate could not ­authorize a medical
treatment decision to withhold or withdraw treatment that would result in your death. You can
give your patient advocate for mental health the power to obtain and consent to mental health
care and treatment that is in your best interest, including arranging for appropriate residential
placement and making payments to secure the necessary treatment.

15. Can I give my patient advocate the authority to make decisions to withhold or withdraw
life-sustaining treatment, including food and water administered through tubes?
Yes, but you must express in a clear and convincing manner that the patient advocate is authorized
to make such decisions, and you must acknowledge that these decisions could or would allow
your death. If you have specific desires as to when you want to forego life-sustaining treatment,
you must describe in the document the specific circumstances in which he or she can act.

16. Do I have the right to express in the document my wishes concerning medical treatment and
personal care?
Yes. You might, for example, express your wishes concerning the type of care you want during
terminal illness. You might also express a desire not to be placed in a nursing home and a desire
to die at home. Your patient advocate has a duty to try to follow your wishes.

17. Is it important to express my wishes in the designation of patient advocate document?

Yes. Your wishes might not be followed if others are unaware of them. It can also be a great
burden for your patient advocate to make a decision for you without your specific guidance.

33
18.  Can I revoke my patient advocate designation?
Yes. A patient may revoke his or her designation at any time and in any manner sufficient to
communicate an intent to revoke. However, for mental health treatment, you may waive your
right to revoke your Patient Advocate Designation for up to 30 days to allow for treatment.

19. Can I appoint a second person to serve as patient advocate in case the first-named person is
unable to serve?
Yes. In fact, this is highly recommended.

20. Must a designation of patient advocate document be witnessed?

Yes. A designation must be executed in the presence of and signed by two witnesses. The witnesses
must not include your spouse, parent, child, grandchild, sibling, presumptive heir, known
devisee at the time of the witnessing, physician, or patient advocate. Witnesses must also not
include an employee of your life or health insurance provider, a health facility that is treating
you, a home for the aged where you reside, or a community mental health services program or
hospital that is providing mental health treatment to you.

21.  In general, what should I do before completing an advance directive?

Give careful consideration to whom you might choose to be your advocate or to act in your
place. Think about your treatment wishes. Discuss the issue with family members. Talk with your
minister, rabbi, priest, or other spiritual leader if you feel it would be helpful. Bring the subject up
with your doctor. Have a discussion about the benefits and burdens of various types of treatment.

22.  Are there issues I should give particular attention to?

Yes. Many people have strong feelings about the administration of food and water, either by
tube down their throat, a tube placed surgically into their stomach, or intravenously. You should
consider and indicate in what circumstances, if any, you wish such procedures withheld or
withdrawn. Also, bear in mind that your opinions regarding your own health care may change
over time. Your wishes regarding medical treatment when you are relatively young may be quite
different from your wishes when you reach advanced age, so you may wish to review your
decisions periodically with your patient advocate.

23. Is there a standard form for an advance directive?

No. While this publication contains a sample form which you may choose to use to designate a
patient advocate, you may use a form designed by an organization, you may hire an attorney to
draft the necessary documentation, or you may write out the document yourself. If you write
the documentation yourself, make sure that it is legible. Under state law, the designation must be
in writing, you must sign the document, date it, and have it witnessed as described above.
A person accepting the responsibility to act as a patient advocate must sign an acceptance to the
designation document which contains provisions required by statute. (These statutory provisions
are listed in sections A through J found in Part VI of the attached Designation of Patient
Advocate form.)

24. What if there is a dispute as to how my designation of patient advocate should be carried out?
If there is a dispute as to whether your patient advocate is acting consistent with your best interest,
the probate court may be petitioned to resolve the dispute. The court can remove a patient
advocate who acts improperly in your behalf.

34
25. What is a funeral representative?
Michigan law allows an individual who is 18 years of age or older and who is of sound mind to
designate another individual who is 18 years of age or older and who is of sound mind to serve as a
funeral representative. This is an individual you designate, in writing, to make decisions about your
funeral arrangements and the handling and disposition of your remains upon your death. Upon
request, the individual you chose must provide a copy of the funeral representative designation to
the funeral establishment.
26. How do I designate a funeral representative?
A funeral representative designation may be included in your will, patient advocate designation,
or other writing. An individual would accept the designation by signing an “Acceptance of Funeral
Representative” or by acting as a funeral representative. The authority of funeral representation
is exercisable only after your death. Such authority and powers are non-delegable to another
individual. To be valid, the “Acceptance of Funeral Representative” must be executed in the
presence of and signed by 2 witnesses or acknowledged before a notary public. The person you
appoint as a funeral representative cannot sign as a witness. The funeral representative also cannot
be an individual who provided nursing care or medical treatment to you immediately before death
or be affiliated with a funeral establishment that will provide services to you, a crematory that will
provide cremation services to you, or a cemetery where you will be buried or entombed unless that
individual is your surviving spouse or relative.

GUIDE FOR USING THE DESIGNATION OF

PATIENT ADVOCATE FORM
The pages following this guide contain a blank copy of a Designation of Patient Advocate form
which you may use to designate your patient advocate. This is a suggested form only. Michigan law
does not require a specific form to be used. If you wish to provide more details in your designation
of patient advocate document, you may attach additional pages to it containing those details. This
guide is intended to help clarify the purposes of the various provisions in this form.
THIS FORM PROVIDES A DESIGNATION OF PATIENT ADVOCATE FOR PURPOSES
OF CARE, CUSTODY, MEDICAL AND MENTAL HEALTH TREATMENT. IF YOU DESIRE A
MORE COMPREHENSIVE DOCUMENT THAT ALSO GRANTS AUTHORITY FOR HANDLING
FINANCIAL, BUSINESS OR PERSONAL AFFAIRS, PLEASE CONSULT AN ATTORNEY.

SECTION I: APPOINTMENT OF ADVOCATE

The first several blanks in the form are for putting your name and the name of the person you are
appointing as your advocate and successor advocate. You may appoint ANY person who is at least
18 years of age or older and of sound mind to be your advocate. It is important that you consult with
the person you are naming and secure his or her consent before naming that person.
The law requires that, before you can be considered unable to participate in medical or mental
health treatment decisions, a determination must be made by your attending physician and at
least one other physician, a licensed psychologist, or a mental health professional. Because some
individuals’ religious beliefs may not allow for an examination by a physician, the document may
state the religious objection and indicate how the determination shall be made.

SECTION II:  REVOCATION

This section clarifies that you may revoke your patient advocate designation at any time by
clearly communicating your intent to do so. With regard to mental health treatment, you may choose
to waive your right to revoke for up to 30 days.

35
SECTION III:  GRANTS OF AUTHORITY AND RESPONSIBILITY
This is a crucial section of the designation of patient advocate document. You may check any, all,
or none of the grants of power. If you do not check any of the options, you will need to attach your
own written grants of power to indicate what powers your advocate will have.
This section contains the very important provision regarding whether decisions to withhold or
withdraw treatment, which would allow you to die, will be made for you. Due to the serious nature
of this granting of power, Michigan law requires that you express in a clear and convincing manner
that your patient advocate is authorized to make such a decision, and that you acknowledge that
such a decision could or would allow your death. If you do grant this authority, you should make
clear to your patient advocate your desires for treatment. Section IV of the form provides a space for
setting forth your specific desires.

SECTION IV:  DESIRES AND PREFERENCES FOR TREATMENT

This is the section of the document where you may state your desires regarding the care, custody,
and medical treatment you want or do not want to receive, and under what circumstances treatment
should be administered, continued, refused, or withdrawn. Here you may direct your treatment
regarding mechanical life-supports (like respirators or kidney dialysis), ordinary or routine treatments
(simple surgeries, use of antibiotics, insulin, heart or blood pressure medications, blood transfusions,
pain medication, etc.), and basic care (including the provision of food and water). As with the other
sections of your designation of patient advocate document, you may attach additional pages if the
space provided is inadequate.
MICHIGAN LAW DOES NOT REQUIRE THAT YOU FILL OUT THIS SECTION OR PROVIDE
AN ATTACHMENT ACCOMPLISHING THE SAME PURPOSE. The law stipulates that your
advocate must act in your best interest and that health care providers should comply with your
advocate’s direction if he or she is reasonably believed to be acting within the authority granted in
your designation of the patient advocate. Thus, directions your advocate gives which are consistent
with your statement in this section are not likely to be questioned.

SECTION V: SIGNATURE AND WITNESSING

Michigan law requires that before a patient advocate can execute any of his or her duties and
responsibilities, he or she must sign an Acceptance to the designation. The first provision of Section V
simply insures that you are aware that this designation must be signed before it becomes effective. It
also will indicate whether the designation and acceptance process were completed at one time.
Next, your signature is required. Finally, the requirements pertaining to the witnessing of the
designation are contained within this section. Please note the limitations on who may serve as a witness.

SECTION VI: ACCEPTANCE OF THE DESIGNATION

As noted above, the advocate whom you name must sign an Acceptance of your designation
before he or she can act on your behalf. Michigan law requires that certain information regarding
the rights, authorities, and limits related to patient advocate designations be contained within this
­Acceptance. The Acceptance provided in Section VI of the form meets these requirements.
The name of the person you are appointing should appear in the first blank, and your name (patient)
should appear in the second blank. The third blank should contain the date on which you signed
your designation of patient advocate document. The Acceptance may be signed on the same day, or
at a later time. Finally, your advocate’s signature and the date of his or her signing are needed at the
end of the Accept­ance.

36
 Designation of Patient Advocate
(Durable Power of Attorney for Health Care)
(Please print or type required information)

I.  Appointment of Patient Advocate

I, _________________________________________________________________________________________
(Your full name)

of ____________________________________________________________________________________________
(Your complete legal address)

hereby appoint ______________________________________________________________________________

(Person you are appointing as your Patient Advocate)

residing at ____________________________________________________________________________________
(Person’s complete address)

as my Patient Advocate with the following power to be exercised in my name and for my benefit,
for the purpose of making decisions regarding my care, custody, and medical and/or mental health
treatment. This Designation of Patient Advocate shall not be affected by my disability or incapacity,
and is governed by sections 700.5506-700.5515 of the Michigan Compiled Laws.

In the event that the above-named Patient Advocate is unable or expresses an intent not to serve as
advocate, I then appoint

___________________________________ residing at _____________________________________________

(Name of successor Patient Advocate) (Address)

to serve as my successor Patient Advocate.

This designation of Patient Advocate shall be exercisable (check one):

n  When my attending physician and at least one other physician or licensed psychologist determine
upon examination that I am unable to participate in medical decisions; puts the determination in
writing; and makes it part of my medical record. For mental health treatment, when a physician
and a mental health professional both certify in writing after examination that I am unable to give
informed consent to mental health treatment.

n My religious beliefs prohibit my examination as detailed above. Therefore, the determination
of my inability to participate in medical decisions or give informed consent to mental health
treatment shall be made as follows:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
(use attached sheet if necessary)

37
I designate the following physician(s) and/or mental health practitioner(s) to make the determination
as to whether I am able to give informed consent for mental health treatment:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

I understand that if any of these individuals are unwilling or unable to make this determination
within a reasonable time, the required examination and determination may be made by another
physician or mental health professional, as appropriate.

Before the powers granted in this designation of patient advocate are exercisable, a copy of it shall be
placed in my medical record with my attending physician and, if applicable, with the facility where I am
located.

Michigan law states that an individual designated as a patient advocate has the following authority,
rights, responsibilities, and limitations:

(a) A
 patient advocate shall act in accordance with the standards of care applicable to fiduciaries in
exercising his or her powers.

(b) A
 patient advocate shall take reasonable steps to follow the desires, instructions, or guidelines
given by the patient while the patient was able to participate in decisions regarding care, custody,
medical treatment, or mental health treatment, as applicable, whether given orally or as written in
the designation.

(c) A
 patient advocate shall not exercise powers concerning the patient’s care, custody, and medical
or mental health treatment that the patient, if the patient were able to participate in the decision,
could not have exercised on his or her own behalf.

(d) The designation cannot be used to make a medical treatment decision to withhold or withdraw
treatment from a patient who is pregnant that would result in the pregnant patient’s death.

(e) A patient advocate may make a decision to withhold or withdraw treatment that would allow a
patient to die only if the patient has expressed in a clear and convincing manner that the patient
advocate is authorized to make such a decision, and that the patient acknowledges that such a
decision could or would allow the patient’s death.

(f) A patient advocate may choose to have the patient placed under hospice care.

(g) A
 patient advocate under this section shall not delegate his or her powers to another individual
without prior authorization by the patient.

(h) W
 ith regard to mental health treatment decisions, the patient advocate shall only consent to the
forced administration of medication or to inpatient hospitalization, other than hospitalization as a
formal voluntary patient under section 415 of the mental health code, 1974 PA 258, MCL 330.1415,

38
 if the patient has expressed in a clear and convincing manner that the patient advocate is
authorized to consent to that treatment. If a patient is hospitalized as a formal voluntary
patient under an application executed by his or her patient advocate, the patient retains the
right to terminate the hospitalization under section 419 of the mental health code, 1974 PA 258,
MCL 330.1419.

A patient advocate designation is suspended when the patient regains the ability to participate in
decisions regarding medical treatment or mental health treatment, as applicable. The suspension is
effective as long as the patient is able to participate in those decisions. If the patient subsequently
is determined under MCL 700.5508 or 700.5515 to be unable to participate in decisions regarding
medical treatment or mental health treatment, as applicable, the patient advocate’s authority,
rights, responsibilities, and limitations are again effective.

II. Revocation
I retain the right to revoke this designation of patient advocate as to medical treatment at any time,
and by any means whereby I may communicate an intent to revoke it.

As to mental health treatment (check one):

n I retain the right to revoke this designation of patient advocate at any time, and by any means
whereby I may communicate an intent to revoke it.

n I waive the right to revoke the powers granted in this Patient Advocate Designation regarding
mental health treatment decisions. This waiver does not affect the rights afforded to me to
terminate formal voluntary hospitalization under MCL 330.1419. Furthermore, if I communicate
at a later time that I wish to revoke this Patient Advocate Designation for mental health treatment
while I am deemed unable to participate in decisions regarding mental health treatment, and I am
receiving mental health treatment at that time, mental health treatment shall not continue for more
than thirty (30) days.

If you wish to revoke a Designation of Patient Advocate, it is best to do it in writing and to provide a
copy of the revocation to your physician, mental health professional or health care facility.

39
III.  Grants of Authority and Responsibility
With respect to my physical and medical treatment, I am granting to my advocate the authorities and
responsibilities indicated below. [Check those you are authorizing and add any additional authorities
and responsibilities below. Use more sheets if necessary.]

n Access to and control over my medical records and information.

n Power to employ and discharge physicians, nurses, therapists, and any other care providers, and
to pay them reasonable compensation.

n Power to give informed consent to receiving any medical treatment or diagnostic, surgical, or
therapeutic procedure.

n Power to refuse, or to authorize the discontinuance of, any medical treatment, or diagnostic,
surgical, or therapeutic procedure.

n I AUTHORIZE MY ADVOCATE TO MAKE A DECISION TO WITHHOLD OR WITHDRAW

TREATMENT THAT WOULD ALLOW MY DEATH AND FURTHER ACKNOWLEDGE THAT
SUCH A DECISION TO WITHHOLD OR WITHDRAW TREATMENT COULD ALLOW MY
DEATH. I INSTRUCT MY ADVOCATE IN SECTION IV AS TO MY DESIRES REGARDING THE
WITHHOLDING OR WITHDRAWAL OF TREATMENT THAT COULD BRING ABOUT MY
DEATH. (If you have checked this item, it is strongly recommended that you use the optional
Section IV to specify your desires.)

n Power to execute waivers, medical authorizations, and such other approval as may be required to
permit or authorize care which I may need, or to discontinue care that I am receiving.

n A
 rrange and consent to inpatient psychiatric hospitalization and treatment as a formal voluntary
patient, pursuant to MCL 330.1415, if it is in my best interest and is the least restrictive treatment
to protect my safety and/or the safety of others. However, if I am hospitalized as a formal
voluntary patient under an application executed by my patient advocate, I retain the right to
terminate the hospitalization in accordance with MCL 330.1419.

n To make an anatomical gift of all or part of my body as I have designated on my Organ Donation
form and in accordance with the Public Health Code, MCL 333.10101 to 333.10123. This authority
remains exercisable after my death.

40
IV. Desires and Preferences for Treatment (optional section)
I understand that my inability to participate in medical treatment decisions may encompass a wide
range of circumstances, including, but not limited to, my being either (a) conscious, but mentally
incompetent, or (b) unconscious and unaware. In light of the wide range of circumstances which
might effectuate this document, my desires and preferences for treatment include:

41
V.  Signature of Patient
I have discussed this designation with my above designated patient advocate who intends to sign the
attached Acceptance to this designation (check one):

n Concurrently with the execution of this document.

n At a future date.

I freely and voluntarily sign this document, in the presence of the below-named witnesses, and it
shall become effective on the date indicated below.

____________________________________________ ____________________________________________
(Your signature) (Date)

__________________________________________________________________________________________
(Print or type full name)

__________________________________________________________________________________________
(Address)

__________________________________________________________________________________________
(City) (State) (Zip)

ATTESTATION OF WITNESSES
As a witness to the execution of this designation of patient advocate, I attest that the person who has
signed this document in my presence appears to be of sound mind and under no duress, fraud, or
undue influence. I further attest that I am not the person’s spouse, parent, child, grandchild, sibling,
presumptive heir, known devisee at the time of this witnessing, physician, the named patient advocate;
or an employee of a life or health insurance provider for the person, a health facility that is treating
the person, a home for the aged as defined in the Public Health Code, MCL 333.20106, where the
person resides, or a community mental health services program or hospital that is providing mental
health treatment to the person.

__________________________________________________________________________________________
(First Witness’s Signature) (Address)

__________________________________________________________________________________________
(Type or Print Name) (City) (State) (Zip)

__________________________________________________________________________________________
(Second Witness’s Signature) (Address)

__________________________________________________________________________________________
(Type or Print Name) (City) (State) (Zip)

42
VI. Acceptance to the Designation of Patient Advocate
I, _________________________________________________________________________ hereby accept the
(Print patient advocate’s name)

responsibilities conferred upon me by_________________________________________________________

(Print patient’s name)

to serve as patient advocate in this document executed on

_______________________________________________. I maintain the right to revoke this acceptance at

(Date)
any time and by any means whereby I may communicate a desire to revoke it. By providing my
signature below, I acknowledge that I have read and understand the requirements of Michigan law
pertaining to the execution of a designation of a patient advocate, set out in sections (A) through (J)
below.

(A) This designation is not effective unless the patient is unable to participate in medical or mental
health treatment decisions. If the patient advocate designation includes the authority to make an
anatomical gift as described in MCL 700.5506, the authority remains exercisable after the patient’s
death.

(B) A
 patient advocate shall not exercise powers concerning the patient’s care, custody, and medical
or mental health treatment that the patient, if the patient were able to participate in the decision,
could not have exercised on his or her own behalf.

 his designation cannot be used to make a medical treatment decision to withhold or withdraw
(C) T
treatment from a patient who is pregnant that would result in the pregnant patient’s death.

(D) A
 patient advocate may make a decision to withhold or withdraw treatment that would allow a
patient to die only if the patient has expressed in a clear and convincing manner that the patient
advocate is authorized to make such a decision, and that the patient acknowledges that such a
decision could or would allow the patient’s death.

(E) A patient advocate shall not receive compensation for the performance of his or her authority,
rights, and responsibilities, but a patient advocate may be reimbursed for actual and necessary
expenses incurred in the performance of his or her authority, rights, and responsibilities.

(F) A
  patient advocate shall act in accordance with the standards of care applicable to fiduciaries
when acting for the patient and shall act consistent with the patient’s best interest. The known
desires of the patient expressed or evidenced while the patient is able to participate in medical or
mental health treatment decisions are presumed to be in the patient’s best interest.

(G) A
 patient may revoke his or her patient advocate designation at any time and in any manner
sufficient to communicate an intent to revoke.

 patient may waive his or her right to revoke the patient advocate designation as to the power
(H) A
to make mental health treatment decisions and, if such a waiver is made, his or her ability to
revoke as to certain treatment will be delayed for up to 30 days after the patient communicates
his or her intent to revoke.

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(I) A
 patient advocate may revoke his or her acceptance to the designation at any time and in any
manner sufficient to communicate an intent to revoke.

(J) A
 patient admitted to a health facility or agency has the rights enumerated in section 20201 of the
Public Health Code, 1978 PA 368, MCL 333.20201.

Some, but not all, of the rights enumerated in section 20201 include:

A patient or resident in a health facility or agency (including a hospital or nursing home) will not
be denied appropriate care on the basis of race, religion, color, national origin, sex, age, disability,
marital status, sexual preference, or source of payment.

Patients and residents are also entitled to:

• inspect, or receive for a reasonable fee, a copy of their medical records, to have the
confidentiality of those records maintained and to refuse the release to a person outside the
health facility or agency except as required by a transfer to another health care facility or
otherwise required by law.

• receive adequate and appropriate care, and to receive from the appropriate individual within
the facility information about his or her medical condition, proposed course of treatment, and
prospects of recovery, in terms which the patient or resident can understand unless medically
contraindicated.

• refuse treatment to the extent provided by the law and to be informed of the consequences
of that refusal. If a refusal of treatment prevents a health facility or its staff from providing
appropriate care according to ethical and professional standards, the relationship with the
patient or resident may be terminated upon reasonable notice.

• information about the facility’s policies and procedures for initiation, review, and resolution of
patient complaints.

• to exercise his or her rights as a patient or resident and as a citizen, and to this end may present
grievances or recommend changes in policies and services on behalf of himself or herself or
others to the health facility or agency staff, to governmental officials, or to another person of
his or her choice within or outside the health facility or agency, free from restraint, interference,
coercion, discrimination, or reprisal.

• receive and examine an explanation of his or her bill regardless of the source of payment and to
receive, upon request, information relating to financial assistance available through the facility.

• associate and have private communications and consultations with his or her physician, attorney,
or any other person of his or her choice, and to send and receive personal mail unopened on
the same day it is received at the health facility or agency, unless medically contraindicated as
documented by the attending physician in the medical record.

(Patient Advocate’s Signature) (Date)

44
Organ Donation

45
Frequently Asked Questions
1. How can I be assured my donation decision will be carried out?
First, register with the Michigan Organ Donor Registry. You may register online at
www.michigan.gov/sos; in person at your local Secretary of State office or by calling Gift of Life at
(800) 482-4881. Once registered, you will receive a heart sticker to place on your license indicating
you are registered with the state’s donor database. This registry consents for all organs. Second,
discuss your wishes with your family and/or patient advocate. You may also fill out the generic
organ donor form to keep with your personal papers or to specify certain organs and/or tissues to
donate.
2. Can the next of kin or a patient advocate consent to a donation if the deceased family member
has not registered as an organ donor or made any provision for organ donation?
Yes. The Public Health Code (PA 368 of 1978) and the Estates and Protected Individuals Code
(PA 386 of 1998) provide for this opportunity.
3.  Can my donation decision be included in a Will?
Yes. However, since organ donations must occur promptly, this is normally ineffective because wills
are rarely read, let alone probated, until long after the time for the organ donation has passed.
4.  Who can be a donor?
Almost anyone. Poor health, poor eyesight, and age do not prohibit you from becoming a donor.
However, some of these factors do influence the likelihood of the tissues being suitable for
transplant. Organs and tissues that cannot be used for transplants, however, can often be used for
research to help scientists find cures or better treatments for serious illness.
5.  Will donation affect my funeral arrangements?
No. The donation is performed within hours after death, so funeral arrangements may proceed as
planned. Removal of organs leaves no visible signs that would interfere with a normal open
casket viewing.
6.  Will my family pay or receive any fees for donation?
No. It is illegal to buy or sell the human body, its eyes, organs, and tissues.
7.  Will the quality of medical treatment be affected if one is a known donor?
Strict laws protect the potential donor. Legal guidelines must be followed before death can be
certified. The physician certifying a patient’s death cannot be involved in any way with the
donation or with the transplant.
8.  How can I obtain more information regarding organ, tissue, and eye donation?
Contact the Gift of Life Michigan on the web at www.giftoflifemichigan.org or toll-free at
(866) 500-5801 for organ and tissue donations. For eye donations, contact Eversight Michigan on
the web at www.eversightvision.org/michigan or toll-free at (800) 247-7250. Your local Secretary of
State office also has donation information available. 

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 ORGAN DONATION FORM

Organ Donor Form

of _______________________________________________________________________________________
(Print or type your name)

In the hope that I may help others, I hereby make this anatomical gift if medically acceptable, to take
effect upon my death. The words and marks below indicate my desires.

I give:
n (a) any needed organs or physical parts

n (b) only the following organs or physical parts:

(Specify the organ(s) or physical part(s))

n (c) my body for anatomical study, for the purposes of transplantation, therapy, medical
research, or education if needed.

Limitations or special wishes, if any: _________________________________________________________

Signed by the donor and at least 1 witness in the presence of each other:

__________________________________________ _____________________________________________
Your Signature Your date of birth

__________________________________________ _____________________________________________
Date signed Your complete address (street, city, state, zip code)

__________________________________________ _____________________________________________
Witness’s Signature Witness’s Signature

__________________________________________ _____________________________________________
Printed Name of Witness Printed Name of Witness
✁

Note: Keep this form with your personal papers and inform family
members of your wishes and where this form is kept.

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upon request, in an alternative, accessible format.
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