Medical Durable Power Of Attorney For Health Care Decisions Form Page 2
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1
2MEDICAL DURABLE POWER OF ATTORNEY
FOR HEALTH CARE DECISIONS
1.
I,_____________________________________________________________, Declarant, hereby appoint:
(Print or Type Your Name)
____________________________________________________
Name of Agent
____________________________________________________
Agent’s Home Telephone Number
____________________________________________________
Agent’s Work Telephone Number
____________________________________________________
Agent’s Home Address
as my agent to make health care decisions for me if and when I am unable to make my own health care decisions. This
gives my agent the power to consent, to refuse or stop any health care, treatment, service or diagnostic procedure. My agent
also has the authority to talk with health care personnel, get information and sign forms necessary to carry out
those decisions.
If the person named as my agent is not available or is unable to act as my agent, then I appoint the following
person(s) to serve in the order listed below:
2. _____________________________________________
3. _________________________________________________
Agent Name
Agent Name
_____________________________________________
_________________________________________________
Home Telephone #
Work Telephone #
Home Telephone #
Work Telephone #
By this document I intend to create a Medical Durable Power of Attorney which shall take effect upon my incapacity to make
my own health care decisions and shall continue during that incapacity.
My agent shall make health care decisions as I may direct below or as I make known to him or her in some other way. If I have
not expressed a choice about the health care in question, my agent shall base his/her decision on what he/she believes to be in
my best interest.
(A) Statement of desires concerning life-prolonging care, treatment, services and procedures:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
(B) Special provisions and limitations:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
BY SIGNING HERE, I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT.
____________________________________________________________________________________________________
SIGNATURE OF PERSON CREATING MEDICAL DURABLE POWER OF ATTORNEY (DECLARANT)
DATE
(Optional But Recommended)
Colorado law does not require this instrument to be witnessed; however, it is recommended to obtain the signature of two wit-
nesses or a notary. This is not required by Colorado law but may make this document more acceptable in other states.
WITNESS:
WITNESS:
Signature:___________________________________________ Signature:_________________________________________
Home Address:_______________________________________ Home Address:_____________________________________
____________________________________________________ __________________________________________________
Date:_______________________________________________ Date:_____________________________________________
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