The Medical Power Of Attorney Page 2
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4objection. You have the right to revoke the authority granted to your agent by informing your agent or your
health or residential care provider orally or in writing or by your execution of a subsequent medical power
of attorney. Unless you state otherwise, your appointment of a spouse dissolves on divorce.
This document may not be changed or modified. If you want to make changes in the document, you
must make an entirely new one.
You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or
ineligible to act as your agent. Any alternate agent you designate has the same authority to make health
care decisions for you.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS
IT IS SIGNED IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES.
THE FOLLOWING PERSONS MAY NOT ACT AS ONE OF THE WITNESSES:
(1)
the person you have designated as your agent;
(2)
a person related to you by blood or marriage;
(3)
a person entitled to any part of your estate after your death under a will or codicil executed by you
or by operation of law:
( 4)
your attending physician;
( 5)
an employee of your attending physician;
( 6)
an employee of a health care facility in which you are a patient if the employee is providing direct
patient care to you or is an officer, director, partner, or business office employee of the health care
facility or of any parent organization of the health care facility; or
(7)
a person who, at the time this power of attorney is executed, has a claim against any part of your
estate after your death.
MEDICAL POWER OF ATTORNEY
DESIGNATION OF HEALTH CARE AGENT
I, - - - - - - - - - - - - - - - - - - - - - - - - - - ( i n s e r t your name) appoint:
Name:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Address:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Phone:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this
document. This medical power of attorney takes effect if I become unable to make my own health care
decisions and this fact is certified in writing by my physician.
LIMITATIONS ON THE DECISION-MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS:
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