Fillable Health Care Power Of Attorney Form (Page 3 of 7) in pdf

H. Providing my medical information at the request of any individual acting as my attorney-in-fact

under a durable power of attorney or as a Trustee or successor Trustee under any Trust

Agreement of which I am a Grantor or Trustee, or at the request of any other individual whom my

health care agent believes should have such information. I desire that such information be

provided whenever it would expedite the prompt and proper handling of my affairs or the affairs of

any person or entity for which I have some responsibility. In addition, I authorize my health care

agent to take any and all legal steps necessary to ensure compliance with my instructions

providing access to my protected health information. Such steps shall include resorting to any

and all legal procedures in and out of courts as may be necessary to enforce my rights under the

law and shall include attempting to recover attorneys’ fees against anyone who does not comply

with this health care power of attorney.

To the extent I have not already made valid and enforceable arrangements during my lifetime that

have not been revoked, exercising any right I may have to authorize an autopsy or direct the

disposition of my remains.

J. Taking any lawful actions that may be necessary to carry out these decisions, including but not

limited to: (i) signing, executing, delivering, and acknowledging any agreement, release,

authorization, or other document that may be necessary, desirable, convenient, or proper in order

to exercise and carry out any of these powers; (ii) granting releases of liability to medical

providers or others; and (iii) incurring reasonable costs on my behalf related to exercising these

powers, provided that this health care power of attorney shall not give my health care agent

general authority over my property or financial affairs.

5. Special Provisions and Limitations.

(Notice: The authority granted in this document is intended to be as broad as possible so that your health

care agent will have authority to make any decisions you could make to obtain or terminate any type of

health care treatment or service. If you wish to limit the scope of your health care agent’s powers, you

may do so in this section. If none of the following are initialed, there will be no special limitations on your

agent’s authority.)

Limitations about Artificial Nutrition or Hydration: In exercising the authority to

make health care decisions on my behalf, my health care agent:

shall NOT have the authority to withhold artificial nutrition (such as through tubes)

OR may exercise that authority only in accordance with the following special

(Initial)

provisions:

shall NOT have the authority to withhold artificial hydration (such as through tubes)

OR may exercise that authority only in accordance with the following special

(Initial)

provisions:

NOTE: If you initial either block but do not insert any special provisions, your

health care agent shall have NO AUTHORITY to withhold artificial nutrition or

hydration.

Health Care Power Of Attorney Form Page 3