Medical Power Of Attorney (Page 2 of 6) in pdf

Medical Power Of Attorney Page 2

Second Alternate Agent

Name:

____________________________________________

Address:

____________________________________________

Phone:

____________________________________________

The original of this document is kept at:

______________________________________________________

The following individuals or institutions have signed copies:

Name:

____________________________________________

Address:

____________________________________________

Name:

____________________________________________

Address:

____________________________________________

DURATION.

I understand that this power of attorney exists indefinitely from the date I execute this

document unless I establish a shorter time or revoke the power of attorney. If I am unable to

make health care decisions for myself when this power of attorney expires, the authority I have

granted my agent continues to exist until the time I become able to make health care decisions

for myself.

(IF APPLICABLE) This power of attorney ends on the following date: _______________

PRIOR DESIGNATIONS REVOKED.

I revoke any prior medical power of attorney.

MEDICAL POWER OF ATTORNEY AND DISCLOSURE STATEMENT

PAGE 2

Medical Power Of Attorney Page 2