Fillable Health Care Power Of Attorney Form (Page 4 of 7) in pdf

Health Care Power Of Attorney Form Page 4

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B. Limitations Concerning Health Care Decisions. In exercising the authority to make

health care decisions on my behalf, the authority of my health care agent is subject

to the following special provisions: [Here you may include any specific provisions

you deem appropriate such as: your own definition of when life-prolonging

(Initial)

measures should be withheld or discontinued, or instructions to refuse any specific

types of treatment that are inconsistent with your religious beliefs, or are

unacceptable to you for any other reason.]

NOTE: DO NOT initial unless you insert a limitation.

C. Limitations Concerning Mental Health Decisions. In exercising the authority to

make mental health decisions on my behalf, the authority of my health care agent is

subject to the following special provisions: [Here you may include any specific

(Initial)

provisions you deem appropriate such as: limiting the grant of authority to make

only mental health treatment decisions, your own instructions regarding the

administration or withholding of psychotropic medications and electroconvulsive

treatment (ECT), instructions regarding your admission to and retention in a health

care facility for mental health treatment, or instructions to refuse any specific types

of treatment that are unacceptable to you.]

NOTE: DO NOT initial unless you insert a limitation.

D. Advance Instruction for Mental Health Treatment. [Notice: This health care power

of attorney may incorporate or be combined with an advance instruction for mental

health treatment, executed in accordance with Part 2 of Article 3 of Chapter 122C of

(Initial)

the General Statutes, which you may use to state your instructions regarding mental

health treatment in the event you lack capacity to make or communicate mental

health treatment decisions. Because your health care agent’s decisions must be

consistent with any statements you have expressed in an advance instruction, you

should indicate here whether you have executed an advance instruction for mental

health treatment]:

NOTE: DO NOT initial unless you insert an indication.

E. Autopsy and Disposition of Remains. In exercising the authority to make decisions

regarding autopsy and disposition of remains on my behalf, the authority of my

(Initial)

health care agent is subject to the following special provisions and limitations.

(Here you may include any specific limitations you deem appropriate such as:

limiting the grant of authority and the scope of authority, or instructions regarding

burial or cremation):

NOTE: DO NOT initial unless you insert a limitation.

Health Care Power Of Attorney Form Page 4

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