Health Care Power Of Attorney Questionnaire Template printable pdf download

Health Care Power Of Attorney Questionnaire Template

HEALTH CARE POWER OF ATTORNEY QUESTIONNAIRE

Please complete this form with as much information as you can and return it to Wendell

L. Hawkins, PA via fax (864) 848-9759 or email

A. YOUR AGENT OR ALTERNATES MUST BE A PERSON WHO IS 18 YEARS OLD OR OLDER

AND OF SOUND MIND. IT MAY NOT BE YOUR DOCTOR OR ANY OTHER HEALTH CARE

PROVIDER THAT IS NOW PROVIDING YOU WITH TREATMENT; OR AN EMPLOYEE OF

YOUR DOCTOR OR PROVIDER; OR A SPOUSE OF THE DOCTOR, PROVIDER, OR

EMPLOYEE; UNLESS THE PERSON IS A RELATIVE OF YOURS.

B. YOU SHOULD INFORM THE PERSON THAT YOU WANT HIM OR HER TO BE YOUR

HEALTH CARE AGENT. YOU SHOULD DISCUSS THIS DOCUMENT WITH YOUR AGENT AND

YOUR PHYSICIAN AND GIVE EACH A SIGNED COPY. IF YOU ARE IN A HEALTH CARE

FACILITY OR A NURSING CARE FACILITY, A COPY OF THIS DOCUMENT SHOULD BE

INCLUDED IN YOUR MEDICAL RECORD.

1. DESIGNATION OF HEALTH CARE AGENT

I, ____________________________________, (Your name), hereby appoint:

(Agent's Name)___________________________________

(Agent's Address)__________________________________

Telephone: home: ____________________ work: ____________________ mobile:

_________________________ as my agent to make health care decisions for me as

authorized in this document.

Successor Agent: If an agent named by me dies, becomes legally disabled, resigns,

refuses to act, becomes unavailable, or if an agent who is my spouse is divorced or

separated from me, I name the following as successors to my agent, each to act alone

and successively, in the order named:

a. First Alternate Agent:_________________________________

Address: ___________________________________________________________

Telephone: home:_________________________ work:__________________ mobile:

_____________________________________

b. Second Alternate Agent: _______________________________________

Address: ______________________________________________

Telephone: home:__________________________ work: ________________________

mobile: ______________________________

Health Care Power Of Attorney Questionnaire Template