Durable Power Of Attorney Form For Health Care Choices & Health Care Choices Directive printable pdf download

Durable Power Of Attorney Form For Health Care Choices & Health Care Choices Directive

DURABLE POWER OF ATTORNEY FOR HEALTH CARE CHOICES

6-PAGE

& HEALTH CARE CHOICES DIRECTIVE

FORM

Part I. Durable power of attorney for health care choices

I, _____________________________________________, _________________________,

Name

Social Security number

appoint

___________________________________________, _____________________________,

Name

Phone

__________________________________________________________________________

Address

as my agent for health care choices when I am unable to make decisions or communicate my

wishes. In the case the person above cannot serve as my agent, or if I am divorced from or

legally separated from the agent above, I appoint the person below:

___________________________________________, _____________________________,

Name

Phone

__________________________________________________________________________

Address

This alternate agent may make health care decisions for me when I am unable to do so or to

communicate my wishes.

This durable power of attorney becomes effective when two physicians certify that I am

incapacitated and unable to make and communicate health care choices.

You may choose to have one physician, instead of two, determine whether

you are incapacitated. If you want to exercise this option — allowing one

physician to determine whether you are incapacitated — initial here.

COMMUNICATING ABOUT THE END OF LIFE

Durable Power Of Attorney Form For Health Care Choices & Health Care Choices Directive