Health Care Power Of Attorney (Page 2 of 4) in pdf

Health Care Power Of Attorney Page 2

HEALTH CARE POWER OF ATTORNEY of

Page

(3)

AGENT AND ALTERNATIVE AGENT UNAVAILABLE: If I revoke the authority of

my agent and first alternate agent, if I have named one, or if neither my agent or alternate, if I

have named one, is willing, able or reasonably available to make health-care decisions for me,

the instructions in this health care directive are nevertheless to be followed without need for the

express authorization of an agent. YES

AGENT’S AUTHORITY: My agent is authorized to make all health-care

(4)

decisions that in my agent’s judgment relate to psychiatric, psychological and emotional care and

treatment, including the right to consent, withhold consent or withdraw consent to any test,

procedure, program of medications or any form of mental health care and treatment and to select

or discharge any mental health care providers or institutions.

WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority

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becomes effective when: (Indicate the applicable options)

my primary physician, or, if I should be in an emergency room or in a treatment setting,

the attending physician determines that I am unable to make my own health-care decisions.

my primary physician, or, if I should be in an emergency room or in a treatment setting,

the attending physician determines that I meet involuntary hospitalization standards.

my primary physician, or, if I should be in an emergency room or in a treatment setting,

the attending physician determines that if I do not receive psychiatric hospitalization or the

treatment as set out in this instrument my condition will quickly deteriorate such that I would

soon meet the standard for involuntary hospitalization.

other. Describe

The above option(s) require a second physician’s opinion. Yes.

I waive the 2

opinion requirement if another physician is not available. Yes

(If I require a second opinion and do not waive the requirement should no second physician be

available, I understand that my advance directive may not become effective.)

Health Care Power Of Attorney Page 2