Living Will And Durable Power Of Attorney For Health Care Page 3
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7I have discussed these decisions with my physician and have also
completed a Physician Orders for Scope of Treatment (POST) form that contains
directions that may be more specific than, but are compatible with, this Directive.
I hereby approve of those orders and incorporate them herein as if fully set forth.
OR
I have not completed a Physician Orders for Scope of Treatment
(POST) form. If a POST form is later signed by my physician, then this living will
shall be deemed modified to be compatible with the terms of the POST form.
A Durable Power of Attorney for Health Care
1.
DESIGNATION OF HEALTH CARE AGENT
None of the following may be designated as your agent:
(1) your treating health care provider;
(2) a non-relative employee of your treating health care provider;
(3) an operator of a community care facility; or
(4) a non-relative employee of an operator of a community care facility.
If the agent or an alternate agent designated in this Directive is my spouse, and our
marriage is thereafter dissolved, such designation shall be thereupon revoked.
I do hereby designate and appoint the following individual as my attorney in fact (agent)
to make health care decisions for me as authorized in this Directive.
(Insert name, address and telephone number of one individual only as your agent to
make health care decisions for you.)
Name of Health Care Agent:
Address of Health Care Agent:
Telephone Number of Health Care Agent:
For the purposes of this Directive, "health care decision" means consent, refusal of
consent, or withdrawal of consent to any care, treatment, service, or procedure to
maintain, diagnose or treat an individual's physical condition.
Living Will and Durable Power of Attorney for Health Care
Page 3 of 7
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