Medical Power Of Attorney (Page 3 of 6) in pdf

DISCLOSURE STATEMENT.

THIS MEDICAL POWER OF ATTORNEY IS AN IMPORTANT LEGAL DOCUMENT.

BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT

FACTS:

Except to the extent you state otherwise, this document gives the person you name as

your agent the authority to make any and all health care decisions for you in accordance with

your wishes, including your religious and moral beliefs, when you are unable to make the

decisions for yourself. Because "health care" means any treatment, service, or procedure to

maintain, diagnose, or treat your physical or mental condition, your agent has the power to make

a broad range of health care decisions for you. Your agent may consent, refuse to consent, or

withdraw consent to medical treatment and may make decisions about withdrawing or

withholding life-sustaining treatment. Your agent may not consent to voluntary inpatient mental

health services, convulsive treatment, psychosurgery, or abortion. A physician must comply with

your agent's instructions or allow you to be transferred to another physician. Your agent's

authority is effective when your doctor certifies that you lack the competence to make health

care decisions.

Your agent is obligated to follow your instructions when making decisions on your behalf.

Unless you state otherwise, your agent has the same authority to make decisions about your

health care as you would have if you were able to make health care decisions for yourself.

It is important that you discuss this document with your physician or other health care

provider before you sign the document to ensure that you understand the nature and range of

decisions that may be made on your behalf. If you do not have a physician, you should talk with

someone else who is knowledgeable about these issues and can answer your questions. You do

not need a lawyer's assistance to complete this document, but if there is anything in this

document that you do not understand, you should ask a lawyer to explain it to you.

The person you appoint as agent should be someone you know and trust. The person must be

18 years of age or older or a person under 18 years of age who has had the disabilities of

minority removed. If you appoint your health or residential care provider (e.g., your physician or

an employee of a home health agency, hospital, nursing facility, or residential care facility, other

than a relative), that person has to choose between acting as your agent or as your health or

residential care provider; the law does not allow a person to serve as both at the same time.

You should inform the person you appoint that you want the person to be your health care

agent. You should discuss this document with your agent and your physician and give each a

signed copy. You should indicate on the document itself the people and institutions that you

intend to have signed copies. Your agent is not liable for health care decisions made in good faith

on your behalf.

Once you have signed this document, you have the right to make health care decisions for

yourself as long as you are able to make those decisions, and treatment cannot be given to you or

Medical Power of Attorney

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Medical Power Of Attorney Page 3