Ohio Durable Power Of Attorney For Health Care Will To Live Form (Page 5 of 7) in pdf

Ohio Durable Power Of Attorney For Health Care Will To Live Form Page 5

(e)

To select and contract with any medical or health care facility on my behalf,

including, but not limited to, hospitals, nursing homes, assisted residence

facilities, and the like; and

(f)

To execute on my behalf any or all of the following:

(1)

Documents that are written consents to medical treatment, or other

similar orders;

(2)

Documents that are written requests that I be transferred to another

facility, written requests to be discharged against medical advice,

or other similar requests; and

(3)

Any other document necessary or desirable to implement health

care decisions that my attorney in fact is authorized to make

pursuant to this document.

DESIGNATION OF ALTERNATE ATTORNEYS IN FACT

Because I wish that an attorney in fact shall be available to exercise the authorities granted

hereunder at all times, I further designate each of the following individuals to succeed to such

authorities and to serve under this instrument, in the order named, if at any time the attorney in

fact first named (or any alternate designee) is not readily available or is unwilling or unable to

serve or to continue to serve:

First Alternate Attorney in Fact

(name)________________________________________________________________________

presently residing at

(address)______________________________________________________________________

_____________________________________________________________________________

(phone number)_________________________________________________________________

Second Alternate Attorney in Fact

(name)________________________________________________________________________

presently residing at

(address)______________________________________________________________________

______________________________________________________________________________

(phone number)_________________________________________________________________

Each alternate shall have and exercise all of the authority conferred above.

NO EXPIRATION DATE

This Durable Power of Attorney for Health Care shall not be affected by my disability or by lapse

of time. This Durable Power of Attorney for Health Care shall have no expiration date.

Page 5 of 7

Ohio Durable Power Of Attorney For Health Care Will To Live Form Page 5