Durable Power of Attorney for Health Care Decisions
I, ______________________________________________, (date of birth) __________________,
select as my Health Care Agent:
Home:________________ Cell: __________________________ Work:_____________________
and give to my agent the power to make health care decisions for me. This power exists only when I
am unable, in the judgment of my attending doctor, to make those health care decisions. My Health
Care Agent must act consistently with my desires as stated in this document or otherwise made
If the first person cannot be my Health Care Agent, I then select the following person to be my
alternate Health Care Agent:
Home:___________________ Cell: ____________________ Work :_______________________
I understand that my Health Care Agent:
will make choices for me only after I cannot make my own choices in the judgment of my doctor.
can tell my doctor to stop giving me health care, even if it is needed to keep me alive.
can make decisions regarding immunizations and vaccinations.
can choose my health care providers, including hospitals, doctors, and end-of-life care.
can look at my medical records and share my health care information as needed.
can sign releases or other forms about my medical treatment.
can decide if I should join a research study.
I now cancel all prior Durable Powers Of Attorney for Health Care Decisions.