Elder Law Check List

Below is a check list of items that are important to have a record of. Please print out this page and fill it out. Keep it in a safe place to refer to in the future.

Name:  
Address:  
Telephone:  
Fax:  
E-mail:  
Durable Power of Attorney
  Date of durable power of attorney:  
  My agent is:  
  Telephone:  
Health Care Proxy
  Date of health care proxy:  
  My health care agent is:  
  Telephone:  
Living Will
   
Will
  Date of will:  
  My executor is:  
  Telephone:  
Trust
  Type of trust:  
Life Insurance Policies
   
   
Safe Deposit Box
  If so, where:  
Medicare Parts A & B
   
Medicare Supplemental Insurance
  Carrier:  
Medicare HMO
  Carrier:  
My Doctor
  Name:  
  Telephone:  
My Attorney
  Name:  
  Telephone:  
Person to Contact in Case of Emergency
  Name:  
  Telephone:  

 

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