Advance Health Care Directive Form Page 2
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5ADVANCE HEALTH CARE DIRECTIVE FORM
PAGE 2 of 5
OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health care
decision for me, I designate as my first alternate agent:
(name of individual you choose as first alternate agent)
(address)
(city)
(state)
(ZIP Code)
(home phone)
(work phone)
OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available
to make a health care decision for me, I designate as my second alternate agent:
(name of individual you choose as second alternate agent)
(address)
(city)
(state)
(ZIP Code)
(home phone)
(work phone)
(1.2)
AGENT'S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to
provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I
state here:
(Add additional sheets if needed.)
(1.3)
WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary
physician determines that I am unable to make my own health care decisions unless I mark the following box.
If I mark this box ( ), my agent's authority to make health care decisions for me takes effect immediately.
(1.4.)
AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney
for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the
extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent
determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the
extent known to my agent.
(1.5)
AGENT'S POSTDEATH AUTHORITY: My agent is authorized to make anatomical gifts, authorize an autopsy, and
direct disposition of my remains, except as I state here or in Part 3 of this form:
(Add additional sheets if needed.)
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