Durable Power Of Attorney For Health Care Page 5
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5(13)
EFFECT OF COPY: A copy of this form has the same effect as the original
unless the original has been revoked.
(14)
REVOCATION: I understand that I may revoke this OPTIONAL ADVANCE
HEALTH-CARE DIRECTIVE at any time, and that if I revoke it, I should promptly notify my
supervising health-care provider and any health-care institution where I am receiving care and
any others to whom I have given copies of this power of attorney. I understand that I may
revoke the designation of an agent either by a signed writing or by personally informing the
supervising health-care provider.
(15)
SIGNATURES: Sign and date the form here:
SIGNATURE OF PERSON GIVING POWER OF ATTORNEY:
____________________________ ____________________________ _________________
Sign your name
Print your name
Date
Address (Street, City , State, Zip)
It is recommended, but not required, that this form be witnessed.
SIGNATURES OF WITNESSES:
First witness:
Second witness:
____________________________________
____________________________________
Sign your name
Sign your name
____________________________________
____________________________________
Print your name
Print your name
____________________________________
____________________________________
Date
Date
_______________
__________________
Address
Address
_______________________
__________________
City, State , Zip
City, State, Zip
Revised 4/9/2008
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