Ohio Durable Power Of Attorney For Health Care Will To Live Form printable pdf download

Ohio Durable Power Of Attorney For Health Care Will To Live Form

State of Ohio

Durable Power of Attorney for Health Care

Will to Live Form

DESIGNATION OF ATTORNEY IN FACT

I, (your name)__________________________________________________________________

presently residing at

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

(“the Principal”), being of sound mind and not under or subject to duress, fraud or undue

influence, intending to create a Durable Power of Attorney for Health Care under Chapter 1337

of the Ohio Revised Code, as amended from time to time, do hereby designate and appoint:

(Name of Attorney in Fact)________________________________________________________

presently residing at

(address of Attorney in Fact)_______________________________________________________

______________________________________________________________________________

(phone number(s) of Attorney in Fact)_______________________________________________

as my attorney in fact who shall act as my agent to make health care decisions for me as

authorized in this document.

GENERAL STATEMENT OF AUTHORITY GRANTED

I hereby grant to my attorney in fact full power and authority to make all health care decisions for

me to the same extent that I could make such decisions for myself if I had the capacity to do so,

at any time during which my attending physician determines that I do not have the capacity to

make informed health care decisions for myself. Such attorney in fact shall have the authority to

give, to withdraw, or to refuse to give informed consent to any medical or nursing procedure,

treatment, intervention, or other measure used to maintain, diagnose or treat my physical or

mental condition. In exercising this authority, my attorney in fact shall make health care

decisions that are consistent with my desires as stated in this document.

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Ohio Durable Power Of Attorney For Health Care Will To Live Form