The Medical Power Of Attorney Page 3
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4DESIGNATION OF ALTERNATE AGENT
(You are not required to designate an alternate agent but you may do so. An alternate agent may
make the same health care decisions as the designated agent if the designated agent is unable or unwilling
to act as your agent. If the agent designated is your spouse, the designation is automatically revoked by
laws if your marriage is dissolved.)
If
the person designated as my agent is unable or unwilling to make health care decisions for me,
I designate the following persons to serve as my agent to make health care decisions for me as authorized
by this document, who serve in the following order:
A. First Alternate Agent
Name:
-------------------------------------------------------------------
Address:
Phone:
-------------------------------------------------------------------
B. Second Alternate Agent
Name:
-------------------------------------------------------------------
Address:
Phone:
-------------------------------------------------------------------
The original of this document is kept at: __________________________________________ _
The following individuals or institutions have signed copies:
Name:
--------------------------------------------------------------------
Address:
Name:
--------------------------------------------------------------------
Address:
DURATION:
I understand that this power of attorney exists indefinitely from the date I execute this document
unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care
decisions for myself when this power of attorney expires, the authority I have granted my agent continues
to exist until the time I become able to make health care decisions for myself.
(IF APPLICABLE) This power of attorney ends on the following date: _ _ _ _ _ _ _ _ _ _ _
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