Medical Power Of Attorney Form Designation Of Health Care Agent printable pdf download

MEDICAL POWER OF ATTORNEY DESIGNATION OF HEALTH CARE AGENT.

I,__________(insert your name) appoint:

Name:___________________________________________________________

Address:________________________________________________________

Phone___________________________________________________________

as my agent to make any and all health care decisions for me, except to the extent I state

otherwise in this document. This medical power of attorney takes effect if I become unable to

make my own health care decisions and this fact is certified in writing by my physician.

LIMITATIONS ON THE DECISION-MAKING AUTHORITY OF MY AGENT ARE

AS FOLLOWS:_____________________________________________________

_____________________________________________________

DESIGNATION OF ALTERNATE AGENT.

(You are not required to designate an alternate agent but you may do so. An alternate

agent may make the same health care decisions as the designated agent if the designated agent is

unable or unwilling to act as your agent. If the agent designated is your spouse, the designation is

automatically revoked by law if your marriage is dissolved.)

If the person designated as my agent is unable or unwilling to make health care decisions

for me, I designate the following persons to serve as my agent to make health care decisions for

me as authorized by this document, who serve in the following order:

A. First Alternate Agent

Name:_____________________________________________

Address:__________________________________________

Phone________________________________________

B. Second Alternate Agent

Name:_____________________________________________

Address:__________________________________________

Phone________________________________________

The original of this document is kept at:

__________________________________________________

The following individuals or institutions have signed copies:

Name:_____________________________________________

Address:__________________________________________

__________________________________________________

Name:_____________________________________________

Address:__________________________________________

__________________________________________________

DURATION.

I understand that this power of attorney exists indefinitely from the date I execute this

document unless I establish a shorter time or revoke the power of attorney. If I am unable to

make health care decisions for myself when this power of attorney expires, the authority I have

granted my agent continues to exist until the time I become able to make health care decisions for

myself.

(IF APPLICABLE) This power of attorney ends on the following date: __________

Medical Power Of Attorney Form Designation Of Health Care Agent