Durable Power Of Attorney For Health Care Form printable pdf download

Durable Power Of Attorney For Health Care Form

Durable Power of Attorney for Health Care Form

Designation of Health Care Agent

I, __________________________appoint:

Name: ____________________________

Address: _________________________________

________________________________________

Phone: __________________________________

as my agent to make any and all health care decisions for me, except to the extent I state

otherwise in this document. This Durable Power of Attorney for Health Care takes effect

if I become unable to make my own health care decisions and this fact is certified in

writing by my physician.

LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE

AS FOLLOWS:

______________________________________________________

Designation of Alternate Agent

(You are not required to designate an alternate agent but you may do so. An alternate

agent may make the same health care decisions as the designated agent if the designated

agent is unable or unwilling to act as your agent. If the agent designated is your spouse,

the designation is automatically revoked by law if your marriage is dissolved.)

If the person designated as my agent is unable or unwilling to make health care decisions

for me, I designate the following persons to serve as my agent to make health care

decisions for me as authorized by this document, who serve in the following order:

A. First Alternate Agent

Name: _______________________________

Address: _____________________________

____________________________________

Phone: _______________________________

Durable Power Of Attorney For Health Care Form