Durable Power of Attorney for Health Care - Alabama

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State of Alabama
Durable Power of Attorney for Health Care
Will to Live Form
Declaration
Declaration made this day of __________________________________, 20___.
I, (your name)__________________________________________________________________
(your address)__________________________________________________________________
_____________________________________________________________________________
(your telephone number(s)________________________________________________________
designate
(attorney in fact’s name)__________________________________________________________
(attorney in fact’s address)________________________________________________________
_____________________________________________________________________________
(attorney in fact’s telephone number(s)______________________________________________
as my health care attorney in fact to make any health care decisions on my behalf, in the matter
set forth in the Natural Death Act, if in the opinion of my attending physician, I am no longer
able to give directions to a health care provider. The attorney in fact designated shall be subject
to the express limitations set forth in this document.
If the person I designate above refuses or is not able to act for me, I designate the following
persons (each to act alone and successively, in the order named):
A. (successor attorney in fact’s name)_______________________________________________
(successor attorney in fact’s address)________________________________________________
(successor attorney in fact’s phone number(s)_________________________________________
B. (second successor attorney in fact’s name)________________________________________
(second successor in fact’s address)_________________________________________________
______________________________________________________________________________
(second successor attorney in fact’s phone number(s)___________________________________
as my health care attorney in fact to make any health care decisions for me subject to the express
limitations set forth in this document.
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