Durable Power Of Attorney Form For Health Care Choices & Health Care Choices Directive (Page 2 of 6) in pdf

Durable Power Of Attorney Form For Health Care Choices & Health Care Choices Directive Page 2

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2 of 6

DURABLE POWER OF ATTORNEY FOR HEALTH CARE & HEALTH CARE DIRECTIVE

By completing this durable power of attorney, I authorize my agent to make all decisions for

me regarding my health care. This includes the power to withdraw any type of health care,

treatment or procedure, even if I may die in the process. I expect my agent to follow my

health care choices directive. My agent has the power to:

Make all necessary arrangements for health care on my behalf. This includes admitting

me to any hospital, psychiatric treatment facility, hospice, nursing home or other health

care facility.

Request, receive and review my medical and hospital records.

Take legal action if necessary to do what I have directed.

Carry out my wishes regarding autopsy and organ donation, and decide what should be

done with my body.

The agent also should not be compensated for services performed for me. However, the

agent shall be reimbursed for reasonable expenses that are part of my care.

THIS IS A DURABLE POWER OF ATTORNEY AND THE AUTHORITY OF MY

ATTORNEY IN FACT, WHEN EFFECTIVE, SHALL NOT TERMINATE OR BE VOID

OR VOIDABLE IF I AM OR BECOME DISABLED OR INCAPACITATED OR IN THE

EVENT OF LATER UNCERTAINTY AS TO WHETHER I AM DEAD OR ALIVE.

LIFE CHOICES

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Durable Power Of Attorney Form For Health Care Choices & Health Care Choices Directive Page 2