North Carolina Statutory Form Health Care Power Of Attorney Page 7
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11spouse, and (ii) they did not know nor have a reasonable expectation that they would be
entitled to any portion of his/her estate upon his/her death under any will or
codicil thereto then existing or under the Intestate Succession Act as it provided at that
time, and (iii) they were not a physician attending him/her, nor an employee of an
attending physician, nor an employee of a health facility in which he/she was a patient, nor
an employee of a nursing home or any group-care home in which he/she resided, and (iv)
they did not have a claim against him/her. I further certify that I am satisfied as to the
genuineness and due execution of the instrument.
This the __________ day of ____________, _______.
___________________________________________
Notary Public
My Commission Expires:
______________________
(A copy of this form should be given to your health care agent and any alternate named in
this power of attorney, and to your physician and family members.)
Health Care Power of Attorney Exercises and Discussion Questions:
1. What is a “health care power of attorney?”
Answer: A “health care power of attorney” gives a “health care agent” broad powers to make
health care decisions for the principal. These powers include the rights to consent to the
principal’s doctor not giving treatment or stopping treatment necessary to keep the principal
alive, admit the principal to a facility, and administer certain treatments (including mental
health treatment) and medications to the principal.
2. What are the “Notice” provisions included at the beginning of “Exhibit C: Health Care
Power of Attorney?”
Answer: The “Notice” provisions of Exhibit C are designed to impress upon the principal the
“broad and sweeping” powers conveyed to the principal by virtue of the health care power of
attorney. These provisions enumerate the specific powers created by the health care power of
attorney, including the health care agent’s rights to consent to the principal’s doctor not
giving treatment or stopping treatment necessary to keep the principal alive, admit the
principal to a facility, and administer certain treatments (including mental health treatment)
and medications to the principal. The Notice provisions advise the principal that he or she
does have the right to express specific limitations or restrictions on the health care agent’s
authority; they also indicate that the health care agent’s power exists only as to those health
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