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

Designation Of Health Care Agent Form - Medical Power Of Attorney Page 5

SIGNATURE IN PRESENCE OF TWO COMPETENT ADULT WITNESSES

I sign my name to this medical power of attorney on

day of

(month, year) at

(City and State)

(Signature)

(Print Name)

STATEMENT OF FIRST WITNESS

I am not the person appointed as agent by this document. I am not related to the principal by blood or marriage. I

would not be entitled to any portion of the principal's estate on the principal's death. I am not the attending physician

of the principal or an employee of the attending physician. I have no claim against any portion of the principal's

estate on the principal's death. Furthermore, if I am an employee of a health care facility in which the principal is a

patient, I am not involved in providing direct patient care to the principal and am not an officer, director, partner, or

business office employee of the health care facility or of any parent organization of the health care facility.

Signature:

Print Name:

Date:

Address:

SIGNATURE OF SECOND WITNESS

Signature:

Print Name:

Date:

Address:

Version 1/01/14

Designation Of Health Care Agent Form - Medical Power Of Attorney Page 5