Durable Power Of Attorney For Health Care Form
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1
2DURABLE POWER OF ATTORNEY FOR HEALTH CARE
This paper says who I want to make health care decisions for me. I want them to do this only if I am too
sick to decide for myself. I want them to try to make the same decisions that I would make if I could.
I want this person to have all the legal rights to OK, refuse or stop medical care for me for a physical or
mental condition. If I need it for mental illness or serious emotional disturbance, I want them to hospital-
ize me.
I want this person to have all the rights I have under the Health Insurance Portability and Accountability
Act of 1996 (HIPAA). This person can get copies of all my medical information.
I want this person to have my durable power
Read this if you have a Living Will. Fill out
of attorney.
the part below:
I want them to have the power to do the things
Does my doctor think I will die no matter
listed above:
what they do?
Name: __________________________________
Then I want this person to make sure my
Living Will is followed. I want them to make
Street Address: ___________________________
sure that I die naturally. This means:
• Not dragging out my dying with machines
City: ________________________ State: ______
or treatment that won’t help.
Day time phone: __________________________
• Giving me only what I need to be comfort-
Night time phone: _________________________
able and out of pain.
Backup attorney in fact:
Does my doctor think I will die no matter
If the person named above cannot or will
what they do? Then this is what else I want.
not serve, I want the following person as
I may not be able to eat or drink. In that case:
my backup attorney in fact. I want them
I DO ____ or DO NOT ____ give this person
to have full powers and responsibilities to
the right to say no to or to stop having me fed
make health care decisions for me.
through a tube or a vein.
Name: __________________________________
When I am dying, I want treatment and medi-
cine to keep me comfortable and out of pain. In
Street Address: _________________________
that case:
City: ________________________ State: ______
I DO ____ or DO NOT ____ give this person the
Day time phone: __________________________
right to OK any treatment or medicine to do
that.
Night time phone: ________________________
I want this treatment and medicine even if it
I give my OK to use copies of this legal
could hurry my death. I want it even if it could
paper. I am signing this Durable Power of
cause addiction. I want it even if it could cause
Attorney for Health Care on the _____ day
permanent physical damage.
of _______________, 20____.
My signature: X_______________________
My signature: X________________________
Person giving the Durable Power of Attorney for Health Care (Principal)
Date: ___________
Do you have a Living Will? If NO, stop here.
Durable Power of Attorney for Health Care p. 1 of 2
5/04 LEGAL AID SOCIETY OF MIDDLE TENNESSEE AND THE CUMBERLANDS
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