Durable Power Of Attorney For Health Care Form (Page 2 of 2) in pdf

Your name (print)______________________________________

3. General Statement of Authority Granted

My Health Care Agent is specifically authorized to give informed consent for health care treatment when I am not capable

of doing so. This includes but is not limited to consent to initiate, continue, discontinue, or forgo medical care and treat-

ment including artificially supplied nutrition and hydration, following and interpreting my instructions for the provision,

withholding, or withdrawing of life-sustaining treatment, which are contained in any Health Care Directive or other form

of “living will” I may have executed or elsewhere, and to receive and consent to the release of medical information. When

the Health Care Agent does not have any stated desires or instructions from me to follow, he or she shall act in my best

interest in making health care decisions.

The above authorization to make health care decisions does not include the following absent a court order:

(1) Therapy or other procedure given for the purpose of inducing convulsion;

(2) Surgery solely for the purpose of psychosurgery;

(3) Commitment to or placement in a treatment facility for the mentally ill, except pursuant to the provisions

of Chapter 71.05 RCW;

(4) Sterilization.

I hereby revoke any prior grants of durable power of attorney for health care.

4. Special Provisions

_____________________________________________________________________________________________________

DATED this _______________________day of ________________________, _______________.

(Year)

GRANTOR (MY SIGNATuRE) ________________________________

STATE OF WASHINGTON

)

)ss.

(COuNTY OF ______________________ )

I certify that I know or have satisfactory evidence that the GRANTOR, ___________________________________________________________

signed this instrument and acknowledged it to be his or her free and voluntary act for the uses and purposes mentioned in the instrument.

DATED this _______________________day of ________________________, _______________.

(Year)

______________________________________________________________________

NOTARY puBLIC in and for the State of Washington,

residing at ______________________________________________________________

My commission expires ____________________________________________________

NOTE: Washington state does not require this directive to be notarized or

witnessed. Since some states do require it to be notarized; you may want to

do so in the event you travel out-of-state.

Durable Power Of Attorney For Health Care Form Page 2