Advance Directive Page 7
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7PART E: ACCEPTANCE BY HEALTH CARE REPRESENTATIVE
I accept this appointment and agree to serve as health care representative. I understand I must act
consistently with the desires of the person I represent, as expressed in this advance directive or
otherwise made known to me. If I do not know the desires of the person I represent, I have a duty to
act in what I believe in good faith to be that person’s best interest. I understand that this document
allows me to decide about that person’s health care only while that person cannot do so. I understand
that the person who appointed me may revoke this appointment. If I learn that this document has been
suspended or revoked, I will inform the person’s current health care provider if known to me.
__________________________________________________________________
(Signature of Health Care Representative/Date)
__________________________________________________________________
(Printed Name)
__________________________________________________________________
(Signature of Alternate Health Care Representative/Date)
__________________________________________________________________
(Printed Name)
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Parent category: Medical