People Who My Health Care Agent Should Include in Decision-Making Steps
I ask that my health care agent make an effort to include these persons in my health care decisions:
Religion / Faith:
I am of the _______________________________________________ faith, and am a part of the
______________________________________________________________ community. Contact
person and phone number of faith community: _____________________________________. I ask
that my health care agent call my faith-based group.
List of Desires, Special Provisions, or Limits
The following are specific instructions for my health care agent and/or doctor providing my health
care. If I need treatment in a state that does not accept this Durable Power of Attorney for Health
Care, or my health care agent cannot be contacted, I want the instructions below to be followed
based on common law and my legal right to direct my own health care.
Instructions for Filling in This Part
You do not have to give any written instructions or make any selections in this section. If you choose
not to give any instructions, your health care agent will make choices based on:
Your verbal instructions
What is felt to be in your best interest
If you choose not to give any instructions, draw a line and write “no instructions” across the page.
Place your initials before each statement that you want your health care agent, your doctor, and
other health care providers to follow.