Alaska Durable Power Of Attorney For Health Care Decisions (Page 6 of 8) in pdf

Alaska Durable Power Of Attorney For Health Care Decisions Page 6

Conditions or limitations:

PART 5

PRIMARY PHYSICIAN

(OPTIONAL)

(12) I DESIGNATE THE FOLLOWING PHYSICIAN AS MY PRIMARY PHYSICIAN:

Name of Physician

Address

City

State

Zip

Phone:

OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act

as my primary physician, I designate the following physician as my primary physician:

Name of Physician

Address

City

State

Zip

Phone:

(13) EFFECT OF COPY. A copy of this form has the same effect as the original.

(14) SIGNATURES.

In the presence of the witnesses or notary public, sign and date the form here:

Signature

Date

Printed Name

Address

City

State

Zip

(15) WITNESSES.

This advance care health directive will not be valid for making health care decisions unless it is

(A) signed by two (2) qualified adult witnesses who are personally known to you and who are present

when you sign or acknowledge your signature; the witnesses may not be a health care provider employed

at the health care institution or health care facility where you are receiving health care, an employee of the

health care provider who is providing health care to you, an employee of the health care institution or

America Living Will Registry, LLC • 2814 Beach Boulevard South • St. Petersburg, FL 33707 • 866-305-ALWR • •

Alaska Durable Power Of Attorney For Health Care Decisions Page 6