Even after you have signed the Durable Power of Attorney for Health Care, you have the right
to make health care decisions for yourself as long as you are able to do so and treatment cannot be given
to you or stopped over your objection. You have the right to revoke the authority granted to your agent by
informing your agent or your health or residential care provider orally or in writing, or by your execution
of a subsequent durable power of attorney for health care. Unless you state otherwise, your appointment
of a spouse dissolves on divorce.
Once completed, the Durable Power of Attorney for Health Care may not be changed or
modified. If you want to make changes in the document, you must make an entirely new one.
You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or
ineligible to act as your agent. Any alternate agent you designate has the same authority to make health
care decisions for you.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESENCE
OF TWO OR MORE OUALIFIED WITNESSES. THE FOLLOWING PERSONS MAY NOT
ACT AS WITNESSES:
1. THE PERSON YOU HAVE DESIGNATED AS YOUR AGENT;
2. YOUR HEALTH OR RESIDENTIAL CARE PROVIDER OR AN EMPLOYEE OF
YOUR HEALTH OR RESIDENTIAL CARE PROVIDER;
3. YOUR SPOUSE;
4. YOUR LAWFUL HEIRS OR BENEFICIARIES NAMED IN YOUR WILL OR A DEED;
5. CREDITORS OR PERSONS WHO HAVE A CLAIM AGAINST YOU.
I have read and understand the contents of this disclosure statement.
Nrsg EOL Form #2 Revised: December 26, 2002 Page 2 of 5