Durable Power Of Attorney For Health Care Decisions
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9PART 1
DURABLE POWER OF ATTORNEY
FOR
HEALTH CARE DECISIONS
(1) DESIGNATION OF AGENT.
I designate the following individual as my agent to make health care decisions for me:
Name
Address
City
State
Zip
Home Phone
Work
OPTIONAL: If I revoke my agent's authority or if my agent is not willing,
able, or reasonably available to make a health care decision for me,
I designate as my first alternate agent:
Name
Address
City
State
Zip
Home Phone
Work
OPTIONAL: If I revoke the authority of my agent and first alternate agent
or if neither is willing, able, or reasonably available to make a health care decision for me,
I designate as my second alternate agent:
Name
Address
City
State
Zip
Home Phone
Work
(2) AGENT'S AUTHORITY.
My agent is authorized and directed to follow my individual instructions and my other
wishes to the extent known to the agent in making all health care decisions for me. If these are
not known, my agent is authorized to make these decisions in accordance with my best interest,
including decisions to provide, withhold, or withdraw artificial hydration and nutrition and
other forms of health care to keep me alive, except as I state here:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
(Add additional sheets if needed.)
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Parent category: Legal