Colorado Medical Durable Power of Attorney for Healthcare
I, _________________________________________________________, hereby appoint:
(name)
________________________________________________________________________
(name of agent)
________________________________________________________________________
(home address of agent)
________________________________________________________________________
(work telephone number of agent)
(home telephone number of agent)
as my agent to make healthcare decisions for me if and when I unable to make my own healthcare decisions. This gives my agent the
power to consent to giving, withholding or stopping any healthcare, treatment, service or diagnostic procedure. My agent also has the
authority to talk with healthcare 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 or unwilling to act as my agent, then I appoint the following person(s) to
serve in the order listed below:
1. _____________________________________________________________________
(name of first alternate)
_______________________________________________________________________
(home address)
_______________________________________________________________________
(work telephone number)
(home telephone number)
2. _____________________________________________________________________
(name of second alternate)
_______________________________________________________________________
(home address)
_______________________________________________________________________
(work telephone number)
(home telephone number)
By this document I intend to create a Medical Durable Power of Attorney which shall take effect upon my incapacity to make my own
healthcare decisions and shall continue during that incapacity. My agent shall make healthcare 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 healthcare in question, my agent shall base
his/her decisions 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.
I sign my name to this form on: _____________________ at: _______________
(date)
________________________________________________________________________
(address)
______________________________________________________
(signature of person creating Medical Durable Power of Attorney)
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