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

Disclosure Statement Form For Medical Power Of Attorney Page 4

Duration

I understand that this power of attorney exists indefinitely from the date I execute this document

unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care

decisions for myself when this power of attorney expires, the authority I have granted my agent

continues to exist until the time I become able to make health care decisions for myself.

(If Applicable) This power of attorney ends on the following date:

Prior Designations Revoked

I revoke any prior medical power of attorney.

Acknowledgement of Disclosure Statement

I have been provided with a disclosure statement explaining the effect of this document. I have

read and understand the information contained in this disclosure statement.

(You Must Date and Sign This Power of Attorney)

I sign my name to this medical power of attorney on

day of

(month, year)

(City and State)

(Signature)

(Print Name)

Statement of First Witness

I am not the person appointed as agent by this document. I am not related to the principal by blood

or marriage. I would not be entitled to any portion of the principal's estate on the principal's death.

I am not the attending physician of the principal or an employee of the attending physician. I have

no claim against any portion of the principal's estate on the principal's death. Furthermore, if I am

an employee of a health care facility in which the principal is a patient, I am not involved in providing

direct patient care to the principal and am not an officer, director, partner, or business office

employee of the health care facility or of any parent organization of the health care facility.

Signature:

Print Name:

Date:

Address:

Signature of Second Witness

Signature:

Print Name:

Date:

Address:

version 10/25/99

Disclosure Statement Form For Medical Power Of Attorney Page 4