Durable Power Of Attorney For Health Care Template Page 7
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11RELIGIOUS AND SPIRITUAL REQUESTS
Do you want your Rabbi, Priest, Clergy, Minister, Imam, Monk, or other spiritual advisor
contacted if you become sick?
INITIAL ONLY ONE:
Yes
No
Name of Rabbi, Priest, Clergy, Minister, Imam, Monk, or other spiritual advisor:
______________________________________________________________________________
Address:______________________________________________________________________
Phone Number: _______________________________________________________________
DURATION
Unless you specify a shorter period in the space below, this power of attorney will exist until it is
revoked.
I do not want this durable power of attorney for health care to exist until revoked. I want this
durable power of attorney for health care to expire on
(Fill in this space ONLY if you want the authority of your agent to end on a specific date.)
REVOCATION
I can revoke this Durable Power of Attorney for Health Care at any time and for any reason
either in writing or orally. If I change my agent or alternative agents or make any other changes,
I need to complete a new Durable Power of Attorney for Health Care with those changes.
P
III: M
T
D
L
ART
AKING
HE
OCUMENT
EGAL
I revoke any prior designations, advance directives, or durable power of attorney for health care.
Date and Signature of Principal
I am thinking clearly, I agree with everything that is written in this document, and I have made
this document willingly.
Signature
Date signed:
_____ My Initials
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