Health Care Power Of Attorney (Page 4 of 6) in pdf

Advance Instruction for Mental Health Treatment. (Notice: This health care power of

attorney may incorporate or be with an advance instruction for mental health,

executed in accordance with Part 2 of Article 3 of 122C of the General Statutes,

________

which you may use to your instructions regarding mental health treatment in event

(Initial)

you lack capacity to make or communicate mental treatment decisions. Because your

health care agent's must be consistent with any statements you have in an advance

instruction, you should indicate here you have executed an advance instruction for

mental treatment):

NOTE: DO NOT initial unless you insert a limitation.

Autopsy and Disposition of Remains. In exercising the authority to make decisions

________

regarding autopsy and disposition of remains on my behalf, the authority of my health

(Initial)

care agent is subject to the following special provisions and limitations. (Here you

may include any specific limitations you deem such as: limiting the grant of authority

and the scope of authority, or instructions regarding burial or cremation):

NOTE: DO NOT initial unless you insert a limitation.

6. Organ Donation.

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

revoked, my health care agent may exercise any right I may have to:

____BB____

donate any needed organs or parts; or

(Initial)

________

donate only the following organs or parts:

(Initial)

______________________________________________________________________

NOTE: DO NOT INITIAL BOTH BLOCKS ABOVE.

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donate my body for anatomical study if needed.

(Initial)

In exercising the authority to make donations, my health care agent is subject to the

following special provisions and limitations: (Here you may include any specific

limitations deem appropriate such as: limiting the grant of authority and the scope of

________

authority, or instructions regarding gifts of body or body parts.)

(Initial)

_________________________________________________________________________

NOTE: DO NOT initial unless you insert a limitation.

NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN THIS INSTRUMENT WITHOUT

YOUR INITIALS.

7. Guardianship Provision.

Health Care Power Of Attorney Page 4