Designation Of Patient Advocate Form And Directions For Durable Power Of Attorney For Health Care Form (Page 3 of 4) in pdf

Organ Donation

I expressly authorize my patient advocate to make a gift of the following (check any that reflect your wishes):

________ any needed organs or body parts for the purposes of transplantation, therapy, medical research, or education

________ only the following listed organs or body parts for the purposes of transplantation, therapy, medical research or

education: ___________________________________________________

________ my entire body for anatomical study

The gift is effective upon my death. Unlike other powers I give to my patient advocate, this power remains after my death.

_________________________________________________________________________

(Sign your name if you wish to give your patient advocate this authority)

This document is to be treated as a Durable Power of Attorney for Health Care and shall survive my disability or incapacity.

If I am unable to participate in making decisions for my care and there is no Patient Advocate or Successor Patient Advocate able to act for me,

I request that the instructions I have given in this document be followed and that this document be treated as conclusive evidence of my wishes.

It is also my intent that anyone participating in my medical treatment shall not be liable for following the directions of my Patient

Advocate that are consistent with my instructions.

This document is signed in the State of Michigan. It is my intent that the laws of the State of Michigan govern all questions concerning its

validity, the interpretation of its provisions and its enforceability. I also intend that it be applied to the fullest extent possible wherever I may be.

Photocopies of this document can be relied upon as though they were originals.

I am providing these instructions of my free will. I have not been required to give them in order to receive or have care withheld

or withdrawn. I am at least eighteen years old and of sound mind.

Signature

Sign Name___________________________________________________________

Date _________________________

Name ________________________________________________________________________________________________

type or print

Address _______________________________________________________________________________________________

Sign and date here in the presence of at least two witnesses who meet the requirements listed in the witness statement below.

If the witness does not personally know the person who is signing this Designation, the witness should ask for identification,

such as a driver’s license.

Only two witnesses are required. Using three will protect the validity of the Designation if one witness is later found

ineligible to be a witness.

Keep the signed original with your personal papers at home. Give signed copies to your doctor, family, the medical facility

where you are being treated and to Patient Advocates. You should review this document from time to time and when there

is a change in your health or family status. When you review it, if it still expresses your intent, date and sign under the

Reaffirmed section below to show you still agree with its contents. If your wishes change,destroy this document, make a

new one and give a copy to everyone who has a copy of the old version.

You should discuss this document with the person you want to have as your Patient Advocate and have him/her sign the

Acceptance of Patient Advocate on the next page.

Witness Statement and Signature

I declare that the person who signed this Designation of Patient Advocate signed it in my presence and is known to me. I also

declare that the person who signed appears to be of sound mind and under no duress, fraud or undue influence and is not my

husband or wife, parent, child, grandchild, brother or sister. I declare that I am not the presumptive heir of the person who signed

above on this page, the known beneficiary of his/her will at the time of witnessing, his/her physician or a person named as the

Patient Advocate. I also declare that I am not an employee of a life or health insurance provider for the person who signed, an

employee of a health facility that is treating him/her, or an employee of a home for the aged where he/she resides and that I am

at least eighteen years old.

Witnesses

Sign Name ______________________

Sign Name______________________

Sign Name _______________________

Name __________________________

Name___________________________

Name ___________________________

type or print

Address ________________________

Address _________________________

Date ___________________________

Date ____________________________

REAFFIRMED

Date _______________________

Signature _____________________________________

Date _______________________

Signature _____________________________________

Date _______________________

Signature _____________________________________

Date _______________________

Signature _____________________________________

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Designation Of Patient Advocate Form And Directions For Durable Power Of Attorney For Health Care Form Page 3

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