Durable Power Of Attorney For Health Care Page 2
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5(2)
AGENT'S AUTHORITY: My agent is authorized to obtain and review medical
records, reports and information about me and to make all health-care decisions for me,
including decisions to provide, withhold or withdraw artificial nutrition, hydration and all other
forms of health care to keep me alive, except as I state here:
______________________________________________________________________________
______________________________________________________________________________
My agent shall be entitled to all of my medical information and records as my personal
representative within the meaning of the Health Insurance Portability and Accountability Act.
(3)
WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE:
Please initial either A or B:
(A)____________My agent's authority becomes effective immediately unless I have revoked the
agent’s authority.
(B) ____________My agent’s authority shall become effective only if I become incapacitated.
My agent shall be entitled to rely on notarized statements from two qualified health care
professionals as to my incapacity.
(4)
AGENT'S OBLIGATION: My agent shall make health-care decisions for me in
accordance with this power of attorney for health care, any instructions I give in Part 2 of this
form and my other wishes to the extent known to my agent. To the extent my wishes are
unknown, my agent shall make health-care decisions which are in my best interest. In
determining my best interest, my agent shall consider my personal values to the extent known to
my agent.
(5)
NOMINATION OF GUARDIAN: If a guardian of my person needs to be
appointed for me by a court, I nominate the agent designated in this form. If that agent is not
willing, able or reasonably available to act as guardian, I nominate the successor agent whom I
have named, in the order designated.
(6)
DURABILITY: This durable power of attorney for health care shall remain in
effect despite my later incapacity.
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