DPA.HC (1-02) -2- Principal______
YOU BY NOTIFYING THE TREATING PHYSICIAN, HOSPITAL, OR OTHER PROVIDER
OF HEALTH CARE ORALLY OR IN WRITING.
8. THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE
DECISIONS FOR YOU HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND
TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS
9. THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF ATTORNEY
FOR HEALTH CARE.
10. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.
1. DESIGNATION OF HEALTH CARE AGENT.
I, ________________________________________(insert your name),
do hereby designate and appoint:
as my attorney-in-fact to make health care decisions for me as
authorized in this document.
(Insert the name and address of the person you wish to
designate as your attorney-in-fact to make health care decision for
you. Unless the person is also your spouse, legal guardian or the
person most closely related to you by blood, none of the following
may be designated as your attorney-in-fact: (1) your treating
provider of health care, (2) an employee of your treating provider
of health care, (3) an operator of a health care facility, or (4) an
employee of an operator of a health care facility.)
2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE.
By this document I intend to create a durable power of attorney
by appointing the person designated above to make health care
decisions for me. This power of attorney shall not be affected by
my subsequent incapacity.
3. GENERAL STATEMENT OF AUTHORITY GRANTED.
In the event that I am incapable of giving informed consent