Durable Power Of Attorney For Health Care Page 7
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15Durable Power of Attorney For Health Care
(Please print or type required information)
1. Appointment of Patient Advocate
I,
Your full name)
(
of
Your complete legal address
(
)
Hereby appoint
Person you are appointing)
(
residing at
Person’s complete legal address
(
)
as my patient advocate with the following power to be exercised in my name and for my benefit, for the
purpose of making decisions regarding my care, custody, and medical treatment. This durable power of
attorney shall not be affected by my disability or incapacity, and is governed by Sections 700.5506 through
700.5512 of the Michigan Complied Laws.
In the event that the above-names patient advocate is unable or expresses intent not to serve as advocate,
I then appoint
residing at
(Name of successor)
(Legal address)
to serve as my patient advocate.
This durable power of attorney shall be exercisable (check one):
□
When my attending physician and at least one other physician or licensed psychologist determines upon
examination that I am unable to participate in medical decisions.
□
If my religious beliefs prohibit my examination by a physician or licensed psychologist, then when
the following events occur:
(use attached sheet if necessary)
Before the powers granted in this durable power of attorney are exercisable, a copy of it shall be placed in
my medical record with my attending physician and, if applicable with the facility where I am located. I
retain the right to revoke this durable power of attorney at any time, and by any means whereby I may
communicate an intent to revoke it.
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