Durable Power Of Attorney For Healthcare Decisions (Page 2 of 8) in pdf

1. DESIGNATION OF HEALTHCARE AGENT

I, _______________________________________ (insert your name) do hereby

designate and appoint:

Name: __________________________________________________________________

Address: ________________________________________________________________

Telephone Number: _______________________________________________________

as my attorney-in-fact to make health care decisions for me as authorized in this

document.

(Insert the name and address of the person you wish to designate as your attorney-in-fact

to make health care decisions for you. Unless the person is also your spouse, legal

guardian or the person most closely related to you by blood, none of the following may

be designated as your attorney-in-fact: (1) your treating provider of health care; (2) an

employee of your treating provider of health care; (3) an operator of a health care facility;

or (4) an employee of an operator of a health care facility.)

2. DESIGNATION OF HEALTHCARE AGENT

By this document, I intend to create a Durable Power of Attorney by appointing the

person designated above to make health care decisions for me. This Power of Attorney

shall be affected by my subsequent incapacity.

3. DESIGNATION OF HEALTHCARE AGENT

In the event that I am incapable of giving informed consent with respect to health care

decisions, I hereby grant to the attorney-in-fact named above full power, and authority to

make health care decisions for me before, or after my death, including: consent, refusal of

consent, or withdrawal of consent to any care, treatment, service or procedure to

maintain, diagnose or treat physical or mental condition, subject only to the limitations

and special provisions, if any, set forth in paragraph 4 or 6.

4. SPECIAL PROVISIONS AND LIMITATIONS

(Your attorney-in-fact is not permitted to consent to any of the following: commitment to

or placement in a mental health treatment facility, convulsive treatment, psychosurgery,

sterilization, or abortion. If there are any other types of treatment or placement that you

do not want your attorney-in-fact’s authority to give consent for or other restrictions you

wish to place on your attorney-in-fact’s authority, you should list them in the space

below. If you do not want any limitations, your attorney-in-fact will have the broad

powers to make health care decisions on your behalf which are set forth in paragraph 3,

except to the extent that there are limits provided by law.)

Durable Power Of Attorney For Healthcare Decisions Page 2