Designation Of Health Care Agent Form - Medical Power Of Attorney (Page 2 of 5) in pdf

Designation Of Health Care Agent Form - Medical Power Of Attorney Page 2

This document may not be changed or modified. If you want to make changes in the document, you must

make an entirely new one.

You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or ineligible

to act as your agent. Any alternate agent you designate has the same authority to make health care

decisions for you.

THIS POWER OF ATTORNEY IS NOT VALID UNLESS:

(1) YOU SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC;

(2) YOU SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES.

THE FOLLOWING PERSONS MAY NOT ACT AS ONE OF THE WITNESSES:

(1) the person you have designated as your agent;

(2) a person related to you by blood or marriage;

(3) a person entitled to any part of your estate after your death under a will or codicil executed by you or

by operation of law;

(4) your attending physician;

(5) an employee of your attending physician;

(6) an employee of a health care facility in which you are a patient if the employee is providing direct

patient care to you or is an officer, director, partner, or business office employee of the health care

facility or of any parent organization of the health care facility; or

(7) a person who, at the time this power of attorney is executed, has a claim against any part of your

estate after your death.

Designation Of Health Care Agent Form - Medical Power Of Attorney Page 2