Durable Power Of Attorney For Health Care Page 5
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14ADVANCE HEALTH CARE DIRECTIVE
MY NAME IS
MY ADDRESS IS:
(Address)
(City)
(State)
(Zip code)
PART 1
DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS
(1) DESIGNATION OF AGENT: I designate the following individual as my agent to
make health care decisions for me:
(Name of individual you choose as agent)
(Address)
City)
(State)
(Zip code)
(Home phone)
(Work phone)
(E-Mail or other means of contact)
OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or
reasonably available to make a health care decision for me, I designate as my first
alternate agent:
(Name of individual you choose as first alternate agent)
(Address)
(City)
(State)
Zip code)
(Home phone)
(Work phone)
(E-Mail or other means of contact)
OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is
willing, able, or reasonably available to make a health care decision for me, I designate as
my second alternate agent:
(Name of individual you choose as second alternate agent)
(Address)
(City)
(State)
Zip code)
(Home phone)
(Work phone)
(E-Mail or other means to contact)
(2) AGENT’S AUTHORITY: (Strike through any of the following provisions you do
not want. You can add provisions on the form or attach additional pages.)
My agent is authorized to make all of the following health care decisions for me:
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