Durable Power Of Attorney For Health Care Decisions Page 7
Download a blank fillable Durable Power Of Attorney For Health Care Decisions in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Durable Power Of Attorney For Health Care Decisions with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9PART 5
PRIMARY PHYSICIAN
(OPTIONAL)
(12) I DESIGNATE THE FOLLOWING PHYSICIAN AS MY
PRIMARY PHYSICIAN:
Name of Physician
Address
City
State
Zip
Phone
OPTIONAL: If the physician I have designated above is not willing, able, or reasonably
available to act as my primary physician, I designate the following physician as my primary
physician:
Name of Physician
Address
City
State
Zip
Phone
(13) EFFECT OF COPY. A copy of this form has the same effect as the original.
(14) SIGNATURES.
In the presence of the witnesses or notary public, sign and date the form here:
Signature
Date
Printed Name
Address
City
State
Zip
(15) WITNESSES.
This advance care health directive will not be valid for making health care decisions
unless it is
(A) signed by two (2) qualified adult witnesses who are personally known to
you and who are present when you sign or acknowledge your signature;
the witnesses may not be a health care provider employed at the health
10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal