Fillable Health Care Power Of Attorney Form (Page 6 of 7) in pdf

Miscellaneous Provisions.

A. Revocation of Prior Powers of Attorney. I revoke any prior health care power of attorney. The

preceding sentence is not intended to revoke any general powers of attorney, some of the

provisions of which may relate to health care; however, this power of attorney shall take

precedence over any health care provisions in any valid general power of attorney I have not

revoked.

B. Jurisdiction, Severability and Durability. This Health Care Power of Attorney is intended to be

valid in any jurisdiction in which it is presented. The powers delegated under this power of

attorney are severable, so that the invalidity of one or more powers shall not affect any others.

This power of attorney shall not be affected or revoked by my incapacity or mental incompetence.

C. Health Care Agent Not Liable. My health care agent and my health care agent's estate, heirs,

successors, and assigns are hereby released and forever discharged by me, my estate, my heirs,

successors, assigns and personal representatives from all liability and from all claims or demands

of all kinds arising out of my health care agent's acts or omissions, except for my health care

agent’s willful misconduct or gross negligence.

D. No Civil or Criminal Liability. No act or omission of my health care agent, or of any other person,

entity, institution, or facility acting in good faith in reliance on the authority of my health care agent

pursuant to this Health Care Power of Attorney shall be considered suicide, nor the cause of my

death for any civil or criminal purposes, nor shall it be considered unprofessional conduct or as

lack of professional competence. Any person, entity, institution, or facility against whom criminal

or civil liability is asserted because of conduct authorized by this Health Care Power of Attorney

may interpose this document as a defense.

E. Reimbursement. My health care agent shall be entitled to reimbursement for all reasonable

expenses incurred as a result of carrying out any provision of this directive.

By signing here, I indicate that I am mentally alert and competent, fully informed as to the contents of this

document, and understand the full import of this grant of powers to my health care agent.

This the _______ day of _________________________, 20____.

___________________________(SEAL)

I hereby state that the principal, ________________________, being of sound mind, signed (or directed

another to sign on the principal's behalf) the foregoing Health Care Power of Attorney in my presence,

and that I am not related to the principal by blood or marriage, and I would not be entitled to any portion of

the estate of the principal under any existing will or codicil of the principal or as an heir under the Intestate

Succession Act, if the principal died on this date without a will. I also state that I am not the principal's

attending physician or mental health treatment provider who is (1) an employee of the principal's

attending physician or mental health treatment provider, (2) an employee of the health facility in which the

principal is a patient, or (3) an employee of a nursing home or any adult care home where the principal

resides. I further state that I do not have any claim against the principal or the estate of the principal.

Date:

___________________________

Witness:

___________________________

Date:

___________________________

Witness:

___________________________

Health Care Power Of Attorney Form Page 6

Related Articles

Related forms

Related Categories