Poudre Valley Hospital printable pdf download

Poudre Valley Hospital

UNIVERSITY OF COLORADO HEALTH

Fort Collins, Colorado

I, ________________________________________________

BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE

PURPOSE AND EFFECT OF THIS DOCUMENT.

Hereby Appoint _____________________________________

I sign my name to this form on (date) ____________________

Name _____________________________________________

X ________________________________________________

Signature

Home Address ______________________________________

My current home address:

__________________________________________________

Phone: H____________________ W____________________

__________________________________________________

as my agent to make health care decisions for me if and when

Date of Birth: _______________________________________

I am unable to make my own health care decisions. This

gives my agent the power to consent to giving, withholding

WITNESSES

or stopping any health care, treatment, service, or diagnostic

procedure. My agent also has the authority to talk with health

I declare that the person who signed acknowledged this

care personnel, get information, and sign forms necessary to

document is personally known to me, that he/she signed or

carry out those decisions.

acknowledged this durable power of attorney in my presence,

and that he/she appears to be of sound mind and under

I hereby expressly authorize any physician, hospital and any

no duress, fraud, or undue influence. I am not the person

other person or organization to release and disclose to my

appointed as agent by this document, nor am I the patient’s

agent any information any of them may have concerning any

health care provider, or an employee of the patient’s health

treatment, diagnosis, recommendation or other facts which

care provider.

they may have concerning my physical condition and any

health care, counsel, treatment, or assistance provided to me

either before or after the execution of this power of attorney,

First Witness

any privilege hereby being expressly waived as to such

Signature: _________________________________________

disclosures.

Home Address: _____________________________________

If the person named as my agent is not available or is unable

__________________________________________________

to act as my agent, then I appoint the following person(s) to

Print Name: ________________________________________

serve in the order below.

Date: _____________________________________________

Name _________________________________________

Second Witness

Home Address __________________________________

Signature: _________________________________________

______________________________________________

Home Address: _____________________________________

Phone: H_________________ W____________________

__________________________________________________

Print Name: ________________________________________

Name _________________________________________

Date: _____________________________________________

Home Address __________________________________

______________________________________________

Patient Identification

Phone: H_________________ W____________________

By this document I intend to create a power of attorney for

health care which shall take effect upon my incapacity to make

my own health care decisions and shall continue during that

incapacity.

REV 12-06

01000200

E-461B

Scan to: Advanced Directives

Poudre Valley Hospital

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