Idaho Durable Power Of Attorney For Health Care Template printable pdf download

IDAHO DURABLE POWER OF ATTORNEY FOR HEALTH CARE

1. Designation of Health Care Agent - I, ______________________________, do hereby designate and

appoint________________________________________________________________________(name, address and

telephone number), as my attorney in fact (agent) to make health care decisions for me as authorized in this document.

For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent

to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical condition.

2. Creation of Durable Power of Attorney for Health Care - By this document I intend to create a durable

power of attorney for health care. This power of attorney shall not be affected by my subsequent incapacity.

3. General Statement of Authority Granted - Subject to any limitations in this document, I hereby grant to my

agent full power and authority to make health care decisions for me to the same extent that I could make such decisions

for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are

consistent with my desires as stated in this document, or otherwise made known to my agent, including, but not limited

to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures.

4. Statement of Desires, Special Provisions, and Limitations - (You can, but are not required to, state your

desires below.) In exercising the authority under this durable power of attorney for health care, my agent shall act

consistently with my desires as stated below and is subject to the special provisions and limitations stated in the living

will. Additional statement of desires, special provisions, and limitations:

{a}

{b}

{c}

5. Inspection and Disclosure of Information Relating to my Physical of Mental Health - Subject to any

limitations in this document, my agent has the power and authority to do all of the following:

{a}

Request, review, and receive any information, verbal or written, regarding my physical or

mental health, including, but not limited to, medical and hospital records;

{b}

Execute on my behalf any releases or other documents that may be required in order to

obtain this information;

{c}

Consent to the disclosure of this information;

{d}

Consent to the donation of any of my organs for medical purposes. (This statement should be crossed

out if organ donation is not desired)

6. Signing Documents, Waivers, and Releases - Where necessary to implement the health care decisions

that my agent is authorized by this document to make, my agent has the power and authority to execute on my behalf

all of the following:

{a}

Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against

Medical Advice."

{b}

Any necessary waiver or release from liability required by a hospital or physician.

7. Designation of Alternate Agents - If the person designated as my agent in Paragraph 1 is not available or

becomes ineligible to act as my agent to make a health care decision for me or loses the mental capacity to make

health care decisions for me, or if I revoke that person's appointment or authority to act as my agent to make health care

decisions for me, then I designate and appoint the following persons to serve as my agent to make health care

decisions for me as authorized in this document, such persons to serve in the order listed below:

First Alternative Agent

Second Alternative Agent

Name:

Address:

Telephone:

8. Prior Designations Revoked - I revoke any prior durable power of attorney for health care.

9. Law That Governs - This durable power of attorney for health care is made by me as an Idaho resident.

This instrument is in the document form prescribed by Idaho Code Section 39-4505 and shall be governed by the Idaho

Natural Death Act.

Idaho Durable Power Of Attorney For Health Care Template

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