Disclosure Statement Form For Medical Power Of Attorney (Page 2 of 4) in pdf

Disclosure Statement Form For Medical Power Of Attorney Page 2

Even after you have signed this document, you have the right to make health care

decisions for yourself as long as you are able to do so and treatment cannot be given to

you or stopped over your objection. You have the right to revoke the authority granted to

your agent by informing your agent or your health or residential care provider orally or in

writing, by your execution of a subsequent medical power of attorney. Unless you state

otherwise, your appointment of a spouse dissolves on divorce.

This document may not be changed or modified. If you want to make changes in the

document, you must make an entirely new one.

You may wish to designate an alternate agent in the event that your agent is unwilling,

unable, or ineligible to act as your agent. Any alternate agent you designate has the same

authority to make health care decisions for you.

This Power of Attorney is not valid unless it is signed in the presence of two competent

adult witnesses. The following persons may not act as ONE of the witnesses:

• the person you have designated as your agent.

• a person related to you by blood or marriage;

• a person entitled to any part of your estate after your death under a will or codicil

executed by you or by operation of law;

• your attending physician;

• an employee of your attending physician;

• an employee of a health care facility in which you are a patient if the employee is

providing direct patient care to you or is an officer, director, partner, or business

office employee of a health care facility or of any parent organization of the health

care facility; or

• a person who, at the time this power of attorney is executed, has a claim against any

part of your estate after your death.

Disclosure Statement Form For Medical Power Of Attorney Page 2