Durable Power Of Attorney For Health Care And Medical Treatment (Page 2 of 3) in pdf

Durable Power Of Attorney For Health Care And Medical Treatment Page 2

6. I specifically direct all health care providers, including physicians, nurses,

therapists and medical and hospital staff to follow the directions of my

attorney-in-fact and such decisions are superior to and shall take precedence

over any decisions made by any member of my family.

7. The rights, powers, and authority of said attorney-in-fact herein granted

shall commence and be in full force and effect immediately.

8. If any agent named by me dies, becomes incompetent, resigns or refuses

to accept the office of agent, I name the following persons (each to act alone

and successively, in the order named) as successor(s) to the agent:

A. _____________________________________________________

B. _____________________________________________________

9. Special instructions: On the following lines I give special instructions

limiting or extending the powers granted to my agent.

_____________________________________________________________

10. I hereby designate _________________ to determine whether I am

unable to make or communicate decisions concerning my medical care and

treatment by virtue of my physical, mental, or emotional disability,

incompetency, incapacity, illness or otherwise. This determination will be

provided in writing and attached to this Durable Power of Attorney For

Health Care and Medical Treatment.

Dated this __________ day of _____________, ___________.

Signature of Principal:

____________________________________________

Social Security Number: ___________ - ________ - __________.

Durable Power Of Attorney For Health Care And Medical Treatment Page 2