Health Care Power Of Attorney printable pdf download

STATE OF NORTH CAROLINA

HEALTH CARE POWER OF

ATTORNEY

COUNTY OF __Guilford____________

NOTE: YOU SHOULD USE THIS DOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE

AGENT IF YOU ARE COMFORTABLE GIVING THAT PERSON BROAD AND SWEEPING POWERS

TO MAKE HEALTH CARE DECISIONS FOR YOU. THERE IS NO LEGAL REQUIREMENT THAT

ANYONE EXECUTE A HEALTH CARE POWER OF ATTORNEY.

EXPLANATION: You have the right to name someone to make health care decisions for you when you

cannot make or communicate those decisions. This form may be used to create a health care power of

attorney, and meets the requirements of North Carolina law. However, you are not required to use this

form, and North Carolina law allows the use of other forms that meet certain requirements. If you prepare

your own health care power of attorney, you should be very careful to make sure it is consistent with North

Carolina law.

This document gives the person you designate as your health care agent broad powers to make health care

decisions for you when you cannot make the decision yourself or cannot communicate your decision to other

people. You should discuss your wishes concerning life-prolonging measures, mental health treatment, and

other health care decisions with your health care agent. Except to the extent that you express specific

limitations or restrictions in this form, your health care agent may make any health care decision you could

make yourself.

This form does not impose a duty on your health care agent to exercise granted powers, but when a power is

exercised, your health care agent will be obligated to use due care to act in your best interests and in

accordance with this document.

This Health Care Power of Attorney form is intended to be valid in any jurisdiction in which it is presented,

but places outside North Carolina may impose requirements that this form does not meet.

If you want to use this form, you must complete it, sign it, and have your signature witnessed by two

qualified witnesses and proved by a notary public. Follow the instructions about which choices you can

initial very carefully. Do not sign this form until two witnesses and a notary public are present to watch

you sign it. You then should give a copy to your health care agent and to any alternates you name. You

should consider filing it with the Advance Health Care Directive Registry maintained by the North Carolina

Secretary of State:

1. Designation of Health Care Agent.

I, ____Bob Bobcat________________, being of sound mind, hereby appoint the following person(s) to serve as my

health care agent(s) to act for me and in my name (in any way I could act in person) to make health care decisions

for me as authorized in this document. My designated health care agent(s) shall serve alone, in the order named.

Name:

___Sue Bobcat_________________

Home Telephone: __XX____________________

Home Address: ____XX_______________________ Work Telephone:

_________________________

___________________________________________ Cellular Telephone: _________________________

Name:

__Tim Bobcat_________________ Home Telephone: _____XX___________________

Home Address: ____xx_______________________ Work Telephone:

__________________________

___________________________________________ Cellular Telephone: __________________________

Name:

___Samantha Bobcat___________ Home Telephone: _XX______________________

Home Address: _____XX______________________ Work Telephone:

_________________________

___________________________________________ Cellular Telephone: _________________________

Any successor health care agent designated shall be vested with the same power and duties as if originally named as

my health care agent, and shall serve any time his or her predecessor is not reasonably available or is unwilling or

unable to serve in that capacity.

Health Care Power Of Attorney

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