Durable Power Of Attorney For Health Care Decisions Page 10
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12PART 5
PRIMARY PHYSICIAN
(OPTIONAL)
(12) I DESIGNATE THE FOLLOWING PHYSICIAN AS MY
PRIMARY PHYSICIAN:
Name of Physician
Address
City
State
Zip
Phone
OPTIONAL: If the physician I have designated above is not willing, able, or reasonably
available to act as my primary physician, I designate the following physician as my primary
physician:
Name of Physician
Address
City
State
Zip
Phone
(13) EFFECT OF COPY. A copy of this form has the same effect as the original.
(14) SIGNATURES.
In the presence of the witnesses or notary public, sign and date the form here:
Signature
Date
Printed Name
Address
City
State
Zip
(15) WITNESSES.
This advance care health directive will not be valid for making health care decisions
unless it is
(A) signed by two (2) qualified adult witnesses who are personally known to
you and who are present when you sign or acknowledge your signature;
the witnesses may not be a health care provider employed at the health
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