Designation Of Patient Advocate Form And Directions For Durable Power Of Attorney For Health Care Form printable pdf download

DESIGNATION OF PATIENT ADVOCATE FORM

and DIRECTIONS for Durable Power of Attorney

for Health Care

This is an important legal document.

You should discuss it with your doctor and attorney if you have questions.

Appointment of Patient Advocate

Here you name someone to act for you regarding your care, custody and treatment. This person is called

a “Patient Advocate.” You may name anyone who is at least eighteen years old and of sound mind. You

may also name one or more persons to act if your first choice cannot.

If you change your mind, you may revoke your appointment of a Patient Advocate at any time.

To my Family, Doctors and All Concerned with my care:

These instructions express my wishes about my health care. I want my family, doctors and everyone else concerned

with my care to act in accord with them.

I appoint the following person my Patient Advocate:

Patient Advocate’s Name ___________________________________________________________________

type or print

Address

_________________________________________________________________________________________

Telephone

____________________________________________

Appointment of Successor Patient Advocate(s)

I appoint the following person(s), in the order listed, my Successor Patient Advocate if my Patient Advocate does

not accept my appointment, is incapacitated, resigns or is removed. My Successor Patient Advocate is to have

the same powers and rights as my Patient Advocate.

Name

___________________________________________________________________________________________

type or print

Address

_________________________________________________________________________________________

Telephone

____________________________________________

Name

___________________________________________________________________________________________

type or print

Address

_________________________________________________________________________________________

Telephone

____________________________________________

My Patient Advocate or Successor Patient Advocate may delegate his/her powers to the next Successor Patient

Advocate if he or she is unable to act.

My Patient Advocate or Successor Patient Advocate may only act if I am unable to participate in making decisions

regarding my medical treatment.

Instructions for Care

This section gives instructions for your care. Cross out and initial any instructions you do not want.

Under instruction l.b., your Patient Advocate has the right to make arrangements for your care but is not

required personally to pay the cost of your care.

Note: Current law does not permit your Patient Advocate to make decisions to withhold or withdraw treatment

if you are pregnant if that decision would result in your death, to engage in homicide or euthanasia, or to force

medical treatment you do not want because of your religious beliefs.

8560-H-038 (R.02/11)

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Designation Of Patient Advocate Form And Directions For Durable Power Of Attorney For Health Care Form

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