Declaration Of Living Will Form, Durable Power Of Attorney For Health Care Template (Page 4 of 4) in pdf

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

_________________________________

[Name of Declarant]

Pursuant to the Arkansas Durable Power of Attorney for Health Care Act (Ark. Code Ann. § 20-

13-104) (the “Act”), I hereby designate and appoint _____________________________ as my agent, or

attorney in fact, to make decisions regarding my health care during periods when my health care provider

has determined that I lack capacity to decide for myself. Specifically, and not to limit any other rights

prescribed under the Act, my attorney-in-fact shall have the power to have access to my medical records

for treatment or payment decisions; to disclose medical records to others for purposes of treatment,

payment, or health care operations; to employ and discharge physicians; to consent to or refuse to consent

to medical procedures, including the withholding or withdrawal of life-sustaining treatment, and nutrition

and hydration, according to my wishes expressed in my Living Will, or, if my wishes are unclear under

the then existing circumstances of my medical condition, then upon consideration of my best interests as

determined by my physician in consultation with my agent; to admit me to hospitals, including

psychiatric hospitals, nursing homes, or hospice care; and to sign all appropriate forms, consents and

releases in connection with any of said matters.

If ___________________________ resigns, or is not able or available to make health care

decisions for me, or if an agent named by me is divorced from me or is my spouse and legally separated

from me, I appoint _____________________________ as successor, with all of the rights and powers

and authority herein stated. The term “health care” shall have the meaning set forth in Ark. Code Ann. §

20-13-104(c). This Durable Power of Attorney for Health Care shall not be affected by my subsequent

disability or incapacity.

SIGNED this _____________ day of ______________________________, 20____.

________________________________________

Signature

We, the undersigned, do hereby certify that the Declarant, ______________________________

subscribed this Durable Power of Attorney for Health Care in our presence, and we, at his or her request,

in his or her presence, and in the presence of each other, signed as attesting witnesses, and we do further

certify that the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without

undue influence, fraud or restraint and that his or her signature was voluntary.

____________________________________

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Witness

____________________________________

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Address

____________________________________

_____________________________________

City, State and Zip Code

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