Fillable Health Care Power Of Attorney Form (Page 5 of 7) in pdf

Health Care Power Of Attorney Form Page 5

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6. Organ Donation.

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

not been revoked, my health care agent may exercise any right I may have to:

donate any needed organs or parts; or

(Initial)

donate only the following organs or parts:

_____________________________________________________________

(Initial)

NOTE: DO NOT INITIAL BOTH BLOCKS ABOVE.

donate my body for anatomical study if needed.

(Initial)

In exercising the authority to make donations, my 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

(Initial)

authority and the scope of authority, or instructions regarding gifts of the body

or body parts):

_______________________________________________________

NOTE: DO NOT initial unless you insert a limitation.

NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN THIS INSTRUMENT

WITHOUT YOUR INITIALS.

7. Guardianship Provision.

If it becomes necessary for a court to appoint a guardian of my person, I nominate the persons

designated in Section 1, in the order named, to be the guardian of my person, to serve without bond

or security. The guardian shall act consistently with G.S. 35A-1201(a)(5).

8. Reliance of Third Parties on Health Care Agent.

A. No person who relies in good faith upon the authority of or any representations by my health care

agent shall be liable to me, my estate, my heirs, successors, assigns, or personal

representatives, for actions or omissions in reliance on that authority or those representations.

B. The powers conferred on my health care agent by this document may be exercised by my health

care agent alone, and my health care agent's signature or action taken under the authority

granted in this document may be accepted by persons as fully authorized by me and with the

same force and effect as if I were personally present, competent, and acting on my own behalf.

All acts performed in good faith by my health care agent pursuant to this power of attorney are

done with my consent and shall have the same validity and effect as if I were present and

exercised the powers myself, and shall inure to the benefit of and bind me, my estate, my heirs,

successors, assigns, and personal representatives. The authority of my health care agent

pursuant to this power of attorney shall be superior to and binding upon my family, relatives,

friends, and others.

Health Care Power Of Attorney Form Page 5

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