Durable Power Of Attorney For Health Care

I, _______________________________________  (the GRANTOR), of:

Street Address:______________________________________

City: __________________________ State: _______________ Zip Code: ______________

Telephone Number: _______________________

Designate and appoint:

Name:_________________________________________________________

Street Address:______________________________________

City: __________________________ State: _______________ Zip Code: ______________

Telephone Number: _______________________

To be my agent and attorney-in-fact for health care decisions with the maximum lawful authority permissible under current law and any future expansion of rights thereunder, subject only to the restrictions imposed herein.

[OPTIONAL:]  If the above attorney-in-fact is unable to reasonably act for any reason, then I designate and appoint the following alternate attorney-in-fact:

Name:_________________________________________________________

Street Address:______________________________________

City: __________________________ State: _______________ Zip Code: ______________

Telephone Number: _______________________

1)  My agent shall have the power to make health care decisions for me in any jurisdiction, including the authority to consent, refuse consent, or withdraw consent to any care, treatment, service, or procedure to maintain, diagnose or treat a physical or mental condition, including directing the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation, and to make decisions about organ donation, autopsy, and disposition of remains, EXCEPT as specifically limited below:

[MAKE REFERENCE TO AND ATTACH ADDITIONAL SHEETS IF NECESSARY; IF NO LIMITATIONS, WRITE “N/A”; DELETE THIS AND ALL OTHER RED TEXT PRIOR TO PRINTING.]
_______________________________________________________________________
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2)  My agent shall have the power to make all necessary arrangements at any hospital, psychiatric treatment facility, hospice, nursing home, or similar institution; to employ or discharge health care personnel including physicians, psychiatrists, therapists, psychologists, nurses, or any other person who is licensed, certified ,or otherwise permitted to administer health care as my agent shall deem necessary for my physical and mental well being.
3)  My agent shall have the power to request, receive, and execute documents and consent and waiver form, to review any information regarding my physical or mental health, including medical and hospital records, and to authorize any release of other documents that may be required in order to obtain such information.
4)  To the maximum extent possible, my agent shall respect and be governed by my special wishes, which are as follows:
[MAKE REFERENCE TO AND ATTACH ADDITIONAL SHEETS IF NECESSARY; IF NONE, WRITE “N/A”; DELETE THIS AND ALL OTHER RED TEXT PRIOR TO PRINTING.]
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5)  This durable power of attorney for health care shall become effective when a licensed physician, if possible, ________________________________________________ of ________________________________________________, determines in writing that I am incapacitated and unable to make my own health-care decisions, unless I initial the following:

_________      If I initial this line, my agent's authority to make health-care
decisions for me shall take effect immediately.
6)  Any durable power of attorney for health care decisions I have previously made is
hereby revoked.
7)  This durable power of attorney for health care shall remain in effect until my death,
or until revoked by me in writing.
8)  Executed this ___________ day of ____________________________, 201(x)___,


by _________________________________________________________________     
Signature of [INSERT NAME OF GRANTOR]

 


WITNESS AFFIDAVIT: 

 
I believe the GRANTOR to be of sound mind and emotionally competent to make this document.  I am not related to the GRANTOR by blood or marriage, nor would I be entitled any portion of the GRANTOR’S estate upon his/her death.  I am not a beneficiary of any life insurance policy the GRANTOR may have.  I am not an attending physician of the GRANTOR.  I am not a spouse, agent, or employee of the attending physician, nor an agent or employee of a health care facility in which the GRANTOR may be a patient.  I am not a patient in a health care facility in which the GRANTOR may be a patient.  I am not a person who has any claim against or interest in any portion of the estate of the GRANTOR upon his/her death.  I am of legal age to witness and sign this document.

 

#1 Witness Signature:___________________________________

Printed Name:_____________________________________________
Street Address:____________________________________________
City:__________________________________ State:___________ Zip Code:_____________

#2 Witness Signature:___________________________________

Printed Name:_____________________________________________
Street Address:____________________________________________
City:__________________________________ State:___________ Zip Code:_____________

(THIS SECTION FOR NOTARY PUBLIC)