North Carolina Statutory Form Health Care Power Of Attorney Page 4
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11any specific types of treatment that are inconsistent with your religious beliefs, or
unacceptable to you for any other reason.):
___________________________________________________
___________________________________________________
___________________________________________________
B. In exercising the authority to make mental health decisions on my behalf, the authority
of my health care agent is subject to the following special provisions and limitations. (Here
you may include any specific limitations you deem appropriate such as: limiting the grant
of authority to make only mental health treatment decisions, your own instructions
regarding the administration or withholding of psychotropic medications and
electroconvulsive treatment (ECT), instructions regarding your admission to and retention
in a health care facility for mental health treatment, or instructions to refuse any specific
types of treatment that are unacceptable to you):
___________________________________________________
___________________________________________________
___________________________________________________
C. (Notice: This health care power of attorney may incorporate or be combined with an
advance instruction for mental health treatment, executed in accordance with Part 2 of
Article 3 of Chapter 122C of the General Statutes, which you may use to state your
instructions regarding mental health treatment in the event you lack sufficient
understanding or capacity to make or communicate mental health treatment decisions.
Because your health care agent's decisions about decisions must be consistent with any
statements you have expressed in an advance instruction, you should indicate here whether
you have executed an advance instruction for mental health treatment.):
___________________________________________________
___________________________________________________
___________________________________________________
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