Durable Power Of Attorney For Healthcare Decisions Form printable pdf download

This form may be photocopied and distributed

Revised Oct. 2006

Durable Power of Attorney for Healthcare Decisions

Take a copy of this with you whenever you go to the hospital or on a trip

It is important to choose someone to make healthcare decisions for you when you cannot make or communicate decisions for yourself.

Tell the person you choose what healthcare treatments you want. The person you choose will be your agent. He or she will have the right

to make decisions for your healthcare. If you DO NOT choose someone to make decisions for you, write NONE on the line for the

agent’ s name.

I, ________________________________________, SS#______________________ (optional), appoint the person named in this

document to be my agent to make my healthcare decisions.

This document is a Durable Power of Attorney for Healthcare Decisions. My agent’ s power shall not end if I become incapacitated or if

there is uncertainty that I am dead. This document revokes any prior Durable Power of Attorney for Healthcare Decisions. My agent may

not appoint anyone else to make decisions for me. My agent and caregivers are protected from any claims based on following this Durable

Power of Attorney for Healthcare. My agent shall not be responsible for any costs associated with my care. I give my agent full power to

make all decisions for me about my healthcare, including the power to direct the withholding or withdrawal of life-prolonging treatment,

including artificially supplied nutrition and hydration/tube feeding. My agent is authorized to

• Consent, refuse, or withdraw consent to any care, procedure, treatment, or service to diagnose, treat, or maintain a physical or mental

condition, including artificial nutrition and hydration;

• Permit, refuse, or withdraw permission to participate in federally regulated research related to my condition or disorder

• Make all necessary arrangements for any hospital, psychiatric treatment facility, hospice, nursing home, or other healthcare

organization; and, employ or discharge healthcare personnel (any person who is authorized or permitted by the laws of the state to

provide healthcare services) as he or she shall deem necessary for my physical, mental, or emotional well -being;

• Request, receive, review, and authorize sending any information regarding my physical or mental health, or my personal affairs,

including medical and hospital records; and execute any releases that may be required to obtain such information;

• Move me into or out of any State or institution;

• Take legal action, if needed;

• Make decisions about autopsy, tissue and organ donation, and the disposition of my body in conformity with state law; and

• Become my guardian if one is needed.

In exercising this power, I expect my agent to be guided by my directions as we discussed them prior to this appointment and/or to be

guided by my Healthcare Directive (see reverse side).

If you DO NOT want the person (agent) you name to be able to do one or other of the above things, draw a line

through the statement and put your initials at the end of the line.

Agent’s name _____________________________________ Phone ____________ Email______________________________

Address______________________________________________________________________________________________

If you do not want to name an alternate, write “none.”

Alternate Agent’s name _____________________________________ Phone ____________ Email_______________________

Address______________________________________________________________________________________________

Execution and Effective Date of Appointment

My agent’ s authority is effective immediately for the limited purpose of having full access to my medical records and to confer with my

healthcare providers and me about my condition. My agent’ s authority to make all healthcare and related decisions for me is effective

when and only when I cannot make my own healthcare decisions.

SIGN HERE

for the Durable Power of Attorney and/or Healthcare Directive forms. Many states require notarization. It is recommended for the

residents of all states. Please ask two persons to witness your signature who are not related to you or financially connected to your estate.

Signature ________________________________________________________________________________ Date___________________

Witness_________________________________________ Date _________ Witness________________________________ Date________

Notarization:

On this _____ day of______________ , in the year of ______, personally appeared before me the person signing, known by me to be the person who

completed this document and acknowledged it as his/her free act and deed. IN WITNESS WHEREOF, I have set my hand and affixed my official

seal in the County of_______________________ , State of _____________________, on the date written above.

Notary Public_________________________________________________

Commission Expires____________________________________________

Durable Power Of Attorney For Healthcare Decisions Form

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