Durable Power Of Attorney For Healthcare (Page 4 of 8) in pdf

4. Specific Instructions Regarding Mental Health Treatment

I understand that I may, but am not required, to designate a physician, mental health practitioner, or both, to

certify, in writing and after examining me, that I am unable to give informed consent to mental health

treatment. If any physician or mental health practitioner whom I designate is unable or unwilling to conduct

the examination and to make this determination within a reasonable time, I understand that another physician

or mental health practitioner, as applicable, shall make the examination and determination.

I designate the following physician(s) and/or mental health practitioner(s) for this purpose

(no designation is made if left blank):

Name of Physician(s) and/or Mental Health Practitioner(s)

With regard to mental health treatment decisions, my Patient Advocate is authorized to consent to the forced

administration of medication, or to inpatient hospitalization (other than hospitalization as a formal voluntary

patient as provided by law) only if I have authorized the Patient Advocate to do so by signing immediately

below. I understand that 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 as provided by law:

If you give the consent described above, sign here:___________________________

I understand that I may revoke my Patient Advocate designation at any time and in any manner sufficient to

communicate intent to revoke. However, I may choose to waive my right to revoke my Patient Advocate

designation as to the power to exercise mental health treatment decisions by making this waiver as part of my

designation document. If I waive this right to revoke, I understand that mental health treatment provided to

me shall not continue for more than 30 consecutive days, and that the waiver does not affect my rights under

section 419 of the Mental Health Code, 1974 PA 258, MCL 330.1419, or as it may be amended or superseded

by another statue.

If you waive your right to revoke your Patient Advocate designation as to the power to exercise mental health

treatment decisions, sign here:___________________________

This document is to be treated as a Durable Power of Attorney for Health Care and shall survive disability or

incapacity.

If I am unable to participate in making decisions for my care and there is no Patient Advocate or successor

Patient Advocate able to act for me, I request that the instructions I have given in this document be followed

and that this document be treated as conclusive evidence of my wishes.

It is also my intent that anyone participating in my medical and/or mental health treatment shall not be liable

for following the directions of my Patient Advocate that are consistent with my instructions.

This document is signed in the State of Michigan. It is my intent that the laws of the State of Michigan

govern all questions concerning its validity, the interpretation of its provisions and its enforceability. I also

intend that it be applied to the fullest extent possible wherever I may be.

Photocopies of this document can be relied upon as though they were originals.

I am providing these instructions of my free will. I have not been required to give them in order to receive or

have care withheld or withdrawn. I am at least eighteen years old and of sound mind.

Durable Power Of Attorney For Healthcare Page 4