Medical Durable Power Of Attorney For Healthcare Decisions Page 2
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2ADDENDUM TO MEDICAL DURABLE POWER OF ATTORNEY – RECOMMENDED, NOT REQUIRED
2. Signature of Witnesses and Notary
1. Signature of the Appointed Agent
Although not required by Colorado law, my signature
The signature of two witnesses and a notary seal are not
below indicates that I have been informed of my
required by Colorado law for proper execution of a
Medical Durable Power of Attorney; however, they may
appointment as a Healthcare Agent under Medical
make the document more acceptable in other states.
Durable Power of Attorney for (name of Declarant)
.
This document was signed by (name of Declarant)
I accept the responsibilities of that appointment, and I
have discussed with the Declarant his or her wishes and
in our presence, and we, in the presence of each other,
preferences for medical care in the event that he or she
and at the Declarant’s request, have signed our names
cannot speak for him- or herself.
below as witnesses. We declare that, at the time the
I understand that I am always to act in accordance with
Declarant signed this document, we believe that he or
his or her wishes, not my own, and that I have full
she was of sound mind and under no pressure or undue
authority to speak with his or her healthcare providers,
influence. We are at least eighteen (18) years old.
examine healthcare records, and sign documents in order
to carry out those wishes. I also understand that my
authority as a Healthcare Agent is only in effect when
Signature of Witness
the Declarant is unable to make his or her own decisions
and that it automatically expires at his or her death.
Printed Name
If I am an alternate Agent, I understand that my
Address
responsibilities and powers will only take effect if the
primary Agent is unable or unwilling to serve.
Primary Agent’s Signature
Signature of Witness
Printed Name
Printed Name
Address
Date
Notary Seal (optional)
Alternate Agent #1 Signature
State of ___________________________
County of
}
Printed Name
SUBSCRIBED and sworn to before me by
, the Declarant,
Date
and
Alternate Agent #2 Signature
and
witnesses, as the voluntary act and deed of the Declarant
Printed Name
this day of
, 20
.
Date
Notary Public
My commission expires:
2
Pursuant to Colorado Revised Statute 15-14.503–509
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