North Carolina Statutory Form Health Care Power Of Attorney Page 2
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A. Name: ________________________
Home Address: ____________________
Home Telephone Number ________Work Telephone Number________
B. Name: ________________________
Home Address: ____________________
Home Telephone Number ________Work Telephone Number________
Each successor health care agent designated shall be vested with the same power and duties
as if originally named as my health care agent.
2. Effectiveness of appointment.
(Notice: This health care power of attorney may be revoked by you at any time in any
manner by which you are able to communicate your intent to revoke to your health care
agent and your attending physician.)
Absent revocation, the authority granted in this document shall become effective when and
if the physician or physicians designated below determine that I lack sufficient
understanding or capacity to make or communicate decisions relating to my health care
and will continue in effect during my incapacity, until my death. This determination shall
be made by the following physician or physicians. For decisions related to mental health
treatment, this determination shall be made by the following physician or eligible
psychologist. (You may include here a designation of your choice, including your attending
physician or eligible psychologist, or any other physician or eligible psychologist. You may
also name two or more physicians or eligible psychologists, if desired, both of whom must
make this determination before the authority granted to the health care agent becomes
effective.):
________________________________________________________________
________________________________________________________________
________________________________________________________________
3. General statement of authority granted.
Except as indicated in section 4 below, I hereby grant to my health care agent named above
full power and authority to make health care decisions, including mental health treatment
decisions, on my behalf, including, but not limited to, the following:
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