Health Care Power Of Attorney (Page 2 of 6) in pdf

2. Effectiveness of Appointment.

My designation of a health care agent expires only when I revoke it. Absent revocation, the authority granted in this

document shall become effective when and if one of the physician(s) listed below determines that I lack capacity to

make or communicate decisions relating to my health care, and will continue in effect during that incapacity, or until

my death, except if I authorize my health care agent to exercise my rights with respect to anatomical gifts, autopsy,

or disposition of my remains, this authority will continue after my death to the extent necessary to exercise that

authority.

1. ____Michael Jordan______________________ (Physician)

2. ____Matthew Stafford____________________ (Physician)

If I have not designated a physician, or no physician(s) named above is reasonably available, the determination that I

lack capacity to make or communicate decisions relating to my health care shall be made by my attending physician.

3. Revocation.

Any time while I am competent, I may revoke this power of attorney in a writing I sign or by communicating my

intent to revoke, in any clear and consistent manner, to my health care agent or my health care provider.

4. General Statement of Authority Granted.

Subject to any restrictions set forth in Section 5 below, I grant to my health care agent full power and authority to

make and carry out all health care decisions for me. These decisions include, but are not limited to:

Requesting, reviewing, and receiving any information, verbal or written, regarding my physical or mental

health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this

information.

Employing or discharging my health care providers.

Consenting to and authorizing my admission to and discharge from a hospital, nursing or convalescent

home, hospice, long-term care facility, or other health care facility.

Consenting to and authorizing my admission to and retention in a facility for the care or treatment of

mental illness.

Consenting to and authorizing the administration of medications for mental health treatment and

electroconvulsive treatment (ECT) commonly referred to as "shock treatment."

Giving consent for, withdrawing consent for, or withholding consent for, X-ray, anesthesia, medication,

surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a

licensed physician, dentist, podiatrist, or other health care provider. This authorization specifically

includes the power to consent to measures for relief of pain.

Authorizing the withholding or withdrawal of life-prolonging measures.

Providing my medical information at the request of any individual acting as my attorney-in-fact under a

durable power of attorney or as a Trustee or successor Trustee under any Trust Agreement of which I am

a Grantor or Trustee, or at the request of any other individual whom my health care agent believes should

have such information. I desire that such information be provided whenever it would expedite the prompt

and proper handling of my affairs or the affairs of any person or entity for which I have some

responsibility. In addition, I authorize my health care agent to take any and all legal steps necessary to

ensure compliance with my instructions providing access to my protected health information. Such steps

shall include resorting to any and all legal procedures in and out of courts as may be necessary to enforce

my rights under the law and shall include attempting to recover attorneys' fees against anyone who does

not comply with this health care power of attorney.

Health Care Power Of Attorney Page 2