Ohio Legal Rights Service’s
Durable Power of Attorney for Health Care Form
This form helps you to direct your care should your doctor decide that you lack capacity to make your own medical decisions.
It is not intended as a substitute for legal advice, and you should contact a lawyer if you have questions about this document
or what it does.
There are two types of advance directives for mental health treatment. One type is the Declaration for Mental Health Treatment
under Revised Code chapter 2135. The second type is the Durable Power of Attorney for Health Care under Revised Code
chapter 1337. The following form is an advance directive under Revised Code chapter 1337, a Durable Power of Attorney for
Health Care form.
Ohio Legal Rights Service is partially funded by, and this form was prepared through, a grant under the Protection and
Advocacy for Mentally Ill Individuals Act administered through the Center for Mental Health Services of the United States
Department of Human Services.
Copyright 2004 by Ohio Legal Rights Service, 50 W. Broad St., Suite 1400, Columbus, Ohio, 43215-5923.
All rights reserved. May be used or reprinted only for advocacy, educational, or other non-proﬁ t use, if OLRS is acknowledged
as the author and if all copyright information in this paragraph is re-printed in full on each copy.
The express written permission of OLRS is required for any other use.
Instructions for ﬁ lling out this form
In this document you name one or more people as your “agent” or “attorney-in-fact”. You authorize your agent to make all
physical and mental health care decisions for you, but only if your attending physician determines that you have lost the
capacity to make informed health care decisions for yourself. You should review each section of this form. You must ﬁ ll in
your name and county of residence; the section appointing an agent; and the signature and date. You must sign the form in
the presence of the witnesses and/or notary public. The declarations should be ﬁ lled out only if you want to provide speciﬁ c
instructions to your agent about your treatment.
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