Durable Power Of Attorney For Health Care Choices & Health Care Choices Directive
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6DURABLE POWER OF ATTORNEy FOR HEALTH CARE CHOICES
6-PAGE
FORM
& HEALTH CARE CHOICES DIRECTIVE
Part I. Durable power of attorney for health care choices
I, _____________________________________________, _________________________,
Name
Social Security number
appoint
___________________________________________, _____________________________,
Name
Phone
__________________________________________________________________________
Address
as my agent for health care choices when I am unable to make decisions or communicate my
wishes. In the case the person above cannot serve as my agent, or if I am divorced from or
legally separated from the agent above, I appoint the person below:
___________________________________________, _____________________________,
Name
Phone
__________________________________________________________________________
Address
This alternate agent may make health care decisions for me when I am unable to do so or to
communicate my wishes.
This durable power of attorney becomes effective when two physicians certify that I am
incapacitated and unable to make and communicate health care choices.
You may choose to have one physician, instead of two, determine whether
you are incapacitated. If you want to exercise this option — allowing one
physician to determine whether you are incapacitated — initial here.
COMMUNICATING ABOUT THE END OF LIFE
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