Health Care Power Of Attorney Page 12
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12 Did You
Remembe
er To ...
□
Fill
out Part I
if you wa
nt to name
e a health c
care agent
t?
□
Nam
me one or
r two back
k‐up agen
nts in case
e your firs
st
cho
oice as he
ealth care
agent is
not avail
able when
n
nee
eded?
□
Talk
k to your
r agents an
nd back‐u
up agent a
about you
ur
valu
ues and
priorities,
and dec
cide whet
ther that’
’s
eno
ough guida
ance or w
hether you
u also wan
nt to mak
e
spe
ecific hea
lth care
decisions
s in the
e advanc
e
dire
ective?
□
If y
you want t
o make sp
pecific deci
isions, fill
out Part II
I,
cho
oosing care
efully amo
ong alterna
atives?
□
Sign
n and dat
te the adv
vance dire
ective in P
Part III, in
n
fron
nt of two w
witnesses w
who also n
need to sig
gn?
□
Loo
ok over th
he “After M
My Death
” form to
see if you
u
wan
nt to fill ou
ut any part
t of it?
□
Ma
ke sure yo
our health
care agent
t (if you na
amed one)
),
you
ur family,
and you
ur doctor
r know a
about you
ur
adv
vance care
planning?
?
□
Giv
ve a copy o
of your ad
dvance dire
ective to y
your health
h
care
e agent, fa
amily mem
mbers, doc
ctor, and h
hospital o
or
nur
rsing home
e if you are
e a patient
t there?
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