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DURABLE POWER OF ATTORNEY FOR HEALTH CARE
DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Health Care Agent)
1. Designation of Health Care Agent. I, , hereby appoint __________________ as my agent (“Agent”) to make all health care decisions for me.
2. Effective Date and Durability __________________
By this document I intend to create a Durable Power of Attorney for Health Care effective upon, _______________and only during, any period of incapacity in which, in the opinion of Agent and attending physician, I am unable to make or communicate a health care decision. Incapacity shall include the inability to make health care decisions effectively for reasons such as mental illness, mental deficiency, incompetency, physical illness or disability, advanced age, chronic use of drugs, or chronic intoxication. Incapacity may be determined (1) by court order or (2) by an attending physician, whose signed statement in recordable form to that effect shall be conclusive evidence of incapacity. A signed statement done as described here may be relied upon without inquiry by any person dealing with the Agent.
3. Agent’s Powers
I grant to my Agent full authority to make decisions for me regarding my health care. I
direct my Agent to follow my desires as stated in this document or otherwise known to my Agent and to attempt to discuss proposed decisions with me to determine my desires if I am able to communicate in any way. If my Agent cannot determine my wishes, my Agent shall make a choice for me based upon what the Agent believes to be in my best interests. My Agent’s authority is intended to be as broad as possible. Accordingly, unless specifically limited by Section 4 below, my Agent is authorized as follows:
A. To consent to, refuse, or withdraw consent to any and all types of medical care, treatment, surgical procedures, diagnostic procedures, medication, and the use of mechanical or other procedures that affect any bodily function, including (but not limited to) artificial respiration, nutritional support and hydration, and cardiopulmonary resuscitation;
B. To have access to medical records and information to the same extent that I am entitled to, including the right to disclose the contents to others;
C. To authorize my admission to or discharge from (even against medical advice) any hospital, nursing home, residential care, assisted living, or similar facility or service;
D. To contract on my behalf for any health care-related service or facility;
E. To hire and fire medical, social service, and other support personnel responsible for my care;
F. To authorize any medication or procedures intended to relieve pain, even though such use may lead to physical damage, addiction, or hasten the moment of (but not intentionally cause) my death;
G. To make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains, to the extent permitted by law.
H. To take any other action necessary to do what I authorize here, including (but not limited to) granting any waiver or release from liability required by any hospital, physician, or other health care provider; signing any documents relating to refusals of treatment or leaving a facility against medical advice; and pursuing any legal action in my name and at the expense of my estate to force compliance with my wishes.
4. Statement of Desire, Special Provisions, and Limitations A. The powers granted above do not include the following powers or are subject to the following rules or limitations:
B. If I have a Health Care Directive (Living Will) executed by me, I specifically
direct my Agent to follow its direction. (initial & date the selection)
I have (initial) (date)_______________ __________
I do not have (initial) (date) _____________ ______________
a Health Care Directive (Living Will) executed by me.
5. Successor Agents
If any Agent named by me shall die, become legally disabled, resign, refuse to act, be
unavailable, I name the following (each to act alone and successively, in the order named) as successors to my Agent. Also, if Agent is or was my spouse and is legally separated or divorced from me: (initial & date selection) ___________ ________
I do want my spouse to continue as my Agent.
(name) (initial) (date)¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬ ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬ ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬______________
I do not want my spouse to continue as my Agent.
(name) __________________________________________________(initial)____(date)________________
I name the following (each to act alone and successively in the order named) as successors to my Agent.
A. First Alternative Agent B. Second Alternative Agent
Name: Name: _____________________
Address: Address: ___________________
Telephone number: __________________
Telephone number: ___________________
6. Nomination of Guardian
If a Guardian of my person should for any reason be appointed, I nominate my Agent (or his or her successor) named above to be the Guardian.
7. Protection of Third Parties Who Rely on My Agent
No person who relies in good faith upon any representations by my Agent or Successor Agent shall be liable to me, or my estate, my heirs or assigns for recognizing the Agent’s authority.
By signing here, I indicate that I understand the contents of this document and the effect of this grant of powers to my Agent. I sign my name to this Durable Power of Attorney for Health Care on this day of ________________ ,
Signature:_______________________
Print Name: _____________________
Address: ________________________
SS NUMBER : ___________________
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