Medical Power Of Attorney Form Designation Of Health Care Agent (Page 2 of 2) in pdf

Medical Power Of Attorney Form Designation Of Health Care Agent Page 2

PRIOR DESIGNATIONS REVOKED.

I revoke any prior medical power of attorney.

ACKNOWLEDGMENT OF DISCLOSURE STATEMENT.

I have been provided with a disclosure statement explaining the effect of this document.

I have read and understand that information contained in the disclosure statement.

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY.)

I sign my name to this medical power of attorney on __________ day of __________

(month, year) at

_____________________________________________

(City and State)

_____________________________________________

(Signature)

_____________________________________________

(Print Name)

STATEMENT OF FIRST WITNESS.

I am not the person appointed as agent by this document. I am not related to the principal

by blood or marriage. I would not be entitled to any portion of the principal's estate on the

principal's death. I am not the attending physician of the principal or an employee of the

attending physician. I have no claim against any portion of the principal's estate on the principal's

death. Furthermore, if I am an employee of a health care facility in which the principal is a

patient, I am not involved in providing direct patient care to the principal and am not an officer,

director, partner, or business office employee of the health care facility or of any parent

organization of the health care facility.

Signature:________________________________________________

Print Name:___________________________________ Date:______

Address:__________________________________________________

SIGNATURE OF SECOND WITNESS.

Signature:________________________________________________

Print Name:___________________________________ Date:______

Address:__________________________________________________

Medical Power Of Attorney Form Designation Of Health Care Agent Page 2