Health Care Power Of Attorney (Page 3 of 6) in pdf

To the extent I have not already made valid and enforceable arrangements during my lifetime that have

not been revoked, exercising any right I may have to authorize an autopsy or direct the disposition of my

remains.

Taking any lawful actions that may be necessary to carry out these decisions, including, but not limited

to: (i) signing, executing, delivering, and acknowledging any agreement, release, authorization, or other

document that may be necessary, desirable, convenient, or proper in order to exercise and carry out any

of these powers; (ii) granting releases of liability to medical providers or others; and (iii) incurring

reasonable costs on my behalf related to exercising these powers, provided that this health care power of

attorney shall not give my health care agent general authority over my property or financial affairs.

5. Special Provisions and Limitations.

(Notice: The authority granted in this document is intended to be as broad as possible so that your health care agent

will have authority to make any decisions you could make to obtain or terminate any type of health care treatment or

service. If you wish to limit the scope of your health care agent's powers, you may do so in this section. If none of

the following are initialed, there will be no special limitations on your agent's authority.)

Limitations about Artificial Nutrition or Hydration: In exercising the authority to

make health care decisions on my behalf, my health care agent:

Shall NOT have the authority to withhold artificial nutrition (such as through tubes)

________

OR may exercise that authority only in accordance with the following special

(Initial)

provisions:

Shall NOT have the authority to withhold artificial hydration (such as through tubes)

________

OR may exercise that authority only in accordance with the following special

(Initial)

provisions:

NOTE: If you initial either block but do not insert any special provisions, your health

care agent shall have NO AUTHORITY to withhold artificial nutrition or hydration.

Limitations Concerning Health Care Decisions. In exercising the authority to make

health care decisions on my behalf, the authority of my health care agent is subject to

________

the following provisions: (Here you may include any specific you deem appropriate

(Initial)

such as: your own definition when life-prolonging measures should be withheld or

discontinued, or instructions to refuse any specific types of that are inconsistent with

your religious beliefs, or are unacceptable to you for any other reason.)

NOTE: DO NOT initial unless you insert a limitation.

Limitations Concerning Mental Health Decisions. In exercising the authority to make

mental health decisions on my behalf, the authority of my health care agent is subject

________

to following special provisions: (Here you may include any provisions you deem

(Initial)

appropriate such as: limiting grant of authority to make only mental health treatment,

your own instructions regarding the administration withholding of psychotropic

medications and treatment (ECT), regarding admission to and retention in a health

care facility for health treatment, or instructions to refuse any specific of treatment

that are unacceptable to you.)

NOTE: DO NOT initial unless you insert a limitation.

Health Care Power Of Attorney Page 3

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