Durable Power Of Attorney For Health Care Decisions Form printable pdf download

DURABLE POWER OF ATTORNEY

FOR HEALTH CARE DECISIONS

CREATION OF DURABLE POWER OF ATTORNEY

I, _________________________________, date of birth ________________, of __________________ (city),

___________________ (county), and _______________________ (state), designate and appoint

Name

______________________________________

Address

______________________________________

Telephone

______________________________________

as my agent to make health care decisions for me as authorized in this document. The decision of my agent shall be

honored. In the event the above-named agent is unwilling or unable to act as my agent, I hereby appoint the following

person(s) to so serve, in the order listed below. (If more than one agent is appointed to serve jointly, I understand that

they must be in agreement on the health care decisions made on my behalf.)

First alternate agent:

Second alternate agent:

Name

_____________________________

Name

________________________________

Address

_____________________________

Address

________________________________

_____________________________

________________________________

Telephone

_____________________________

Telephone

________________________________

GENERAL STATEMENT OF AUTHORITY GRANTED

Pursuant to the language stated below, on my behalf my agent may:

(1)

Consent, refuse consent, or withdraw consent to any care, treatment, service, or procedure to maintain, diagnose,

or treat a physical or mental condition and to make decisions about organ donation, autopsy, and disposition of

my body;

(2)

Make all necessary arrangements at any hospital, psychiatric hospital, or psychiatric treatment facility, hospice,

nursing home, or similar institution; to employ or discharge health care personnel to include physicians,

psychiatrists, psychologists, dentists, nurses, therapists, or any other person who is licensed, certified, or

otherwise authorized or permitted by the laws of this state to administer health care as the agent shall deem

necessary for my physical, mental, and emotional well being;

(3)

Request, receive, and review any information, verbal or written, regarding my personal affairs or physical or

mental health including medical and hospital records and to execute any releases or other documents that may be

required in order to obtain such information; and

(4)

Execute any appropriate authorizations for the use or disclosure of my protected health information.

In exercising this grant of authority, my agent shall be guided by my expressed desires, including the following:

(Insert any special instructions to be followed by the agent, such as a living will declaration, statements relating to the

principal’s meaningful quality of life, or other guidance.)

__________________________________________________________________________________________________

00003720S

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DPOA

Durable Power Of Attorney For Health Care Decisions Form

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