Durable Power Of Attorney For Healthcare (Page 5 of 8) in pdf

Signature

Sign Name ______________________________________________________ Date____________________________

Name ___________________________________________________________________________________

type or print

Address _________________________________________________________________________________

_______________________________________________________________________________________

Witness Statement and Signature

If the witness does not personally know the person who is signing this Designation, the witness should

ask for identification, such as a driver’s license.

Only two witnesses are required. Using three will protect the validity of the Designation if one witness

if later found ineligible to be a witness.

Keep the signed original with your personal papers at home. Give signed copies to your doctor, family,

and the medical facility where you are being treated and to Patient Advocates.

I declare that the person who signed this Designation of Patient Advocate signed it in my presence and is

known to me. I also declare that the person who signed appears to be of sound mind and under no duress,

fraud or undue influence and is not my husband or wife, parent, child, grandchild, brother, or sister. I declare

that I am not the presumptive heir of the person who signed the previous page, the known beneficiary of

his/her will at the time of witnessing, his/her physician or a person named as the Patient Advocate. I also

declare that I am not an employee of a life or health insurance provider for the person who signed, an

employee of a health facility that is treating him/her, or an employee of a home for the aged where he/she

resides, or a community mental health services program or hospital that is providing mental health treatment

to the person, and that I am at least eighteen years old.

Witness

Sign Name ___________________________________

Sign Name________________________________

Name _______________________________________

Name ____________________________________

Type or print

Address _____________________________________

Address __________________________________

____________________________________________

_________________________________________

Date ________________________________________

Date _____________________________________

Sign Name ___________________________________

Name _______________________________________

Type or print

Address _____________________________________

____________________________________________

Date ________________________________________

These restrictions are required by the Patient Advocate Act of 1990, P.A. No. 312 (MCLA 700.496) and

Public Act 386, 1998.

Durable Power Of Attorney For Healthcare Page 5