Colorado Durable Power Of Attorney For Health Care Will To Live Form

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Colorado Durable Power of Attorney for Health Care
Will to Live Form
I, (your name)__________________________________________________________________
(your address)__________________________________________________________________
_____________________________________________________________________________
(your phone number)____________________________________________________________
designate:
(Name of agent)________________________________________________________________
(address of agent)_______________________________________________________________
(phone number(s) of agent)_______________________________________________________
as my health care attorney-in-fact and agent to make any health care decisions for me as
authorized in this declaration consistent with the instructions below.
If the person I designate above refuses or is unable to act for me, I designate the following
persons (each to act alone and successively, in the order named):
A. First Successor Agent
(successor agent’s name)_________________________________________________________
(successor agent’s address)________________________________________________________
_____________________________________________________________________________
(successor agent’s phone number)__________________________________________________
B. Second Successor Agent
(second successor agent’s name)___________________________________________________
(second successor agent’s address)__________________________________________________
______________________________________________________________________________
(second successor agent’s phone number)____________________________________________
as my health care attorney(s)-in-fact and agent(s) to make any health care decisions for me as
authorized in this document consistent with the instructions below.
This designation shall become effective only when I become incapable of making and
communicating my own health care decisions.
Any prior designation is revoked.
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