MEDICAL DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS
I. APPOINTMENT OF AGENT AND
II. WHEN AGENT’S POWERS BEGIN
ALTERNATES
By this document, I intend to create a Medical Durable
Power of Attorney which shall take effect either
(initial
I, ____________________________________ ,
:
one)
Declarant, hereby appoint:
______ (Initials) Immediately upon my signature.
Name of Agent
______ (Initials) When my physician or other qualified
medical professional has determined that I am unable to
make my or express my own decisions, and for as long
Agent’s Best Contact Telephone Number
as I am unable to make or express my own decisions.
Agent’s email or alternative telephone number
III. INSTRUCTIONS TO AGENT
My Agent shall make healthcare decisions as I direct
Agent’s home address
below, or as I make known to him or her in some other
way. If I have not expressed a choice about the decision
as my Agent to make and communicate my healthcare
or healthcare in question, my Agent shall base his or her
decisions when I cannot. This gives my Agent the
decisions on what he or she, in consultation with my
power to consent to, or refuse, or stop any healthcare,
healthcare providers, determines is in my best interest. I
treatment, service, or diagnostic procedure. My Agent
also request that my Agent, to the extent possible,
also has the authority to talk with healthcare personnel,
consult me on the decisions and make every effort to
get information, and sign forms as necessary to carry out
enable my understanding and find out my preferences.
those decisions.
State here any desires concerning life-sustaining
If the person named above is not available or is unable
procedures, treatment, general care and services,
to continue as my Agent, then I appoint the following
including any special provisions or limitations:
person(s) to serve in the order listed below.
Name of Alternate Agent #1
Agent’s Best Contact Telephone Number
Agent’s email or alternative telephone number
Agent’s home address
Name of Alternate Agent #2
Agent’s Best Contact Telephone Number
My signature below indicates that I understand the
Agent’s email or alternative telephone number
purpose and effect of this document:
Agent’s home address
Signature of Declarant
Date
1
Pursuant to Colorado Revised Statute 15-14.503–509