Health Care Power Of Attorney Page 9
Download a blank fillable Health Care Power Of Attorney in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health Care Power Of Attorney with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12A
M
D
FTER
Y
EATH
(This document is optional. Do only what reflects your wishes.)
By:
Date of Birth:
(Print Name) (Month/Day/Year)
P
I:
O
D
ART
RGAN
ONATION
(Initial the ones that you want. Cross through any that you do not want.)
✎
Upon my death I wish to donate:
✎
Any needed organs, tissues, or eyes.
Only the following organs, tissues or eyes:
I authorize the use of my organs, tissues, or eyes:
✎
For transplantation
✎
For therapy
✎
For research
✎
For medical education
✎
For any purpose authorized by law
I understand that no vital organ, tissue, or eye may be removed for
transplantation until after I have been pronounced dead. This document is not intended to
change anything about my health care while I am still alive. After death, I authorize any
appropriate support measures to maintain the viability for transplantation of my
organs, tissues, and eyes until organ, tissue, and eye recovery has been completed. I
understand that my estate will not be charged for any costs related to this donation.
P
II: D
B
ART
ONATION OF
ODY
After any organ donation indicated in Part I, I wish my body to be donated for
use in a medical study program.
✎______________
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal