The Medical Power Of Attorney Page 4
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4PRIOR DESIGNATIONS REVOKED
I revoke any prior medical power of attorney.
ACKNOWLEDGEMENT OF DISCLOSURE STATEMENT
I
have been provided with a disclosure statement explaining the effect of this document.
I
have read
and understand that information contained in the disclosure statement.
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY.)
I
sign my name to this medical power of attorney on the
day of _ _ _ _ _ _ _ _ _ _ _ _
(month, year)
at
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
(City and State)
(Signature)
(Print
N
arne)
STATEMENT OF FIRST WITNESS
I
am not the person appointed as agent by this document.
I
am not related to the principal by blood or
marriage.
I
would not be entitled to any portion of the principal's estate on the principal's death.
I
am not
the attending physician of the principal or an employee of the attending physician. I have no claim against
any portion of the principal's estate on the principal's death. Furthermore, ifl am an employee of a health
care facility in which the principal is a patient,
I
am not involved in providing direct patient care to the
principal and am not an officer, director, partner, or business office employee of the health care facility
or of any parent organization of the health care facility.
Signature:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PrintName:
Date:
- - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - -
Address:
SIGNATURE OF SECOND WITNESS
Signature: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Print Name:
Date:
- - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - -
Address:
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