Durable Power of Attorney for Healthcare Decisions

Durable Power of Attorney for Healthcare Decisions
Take a copy of this with you whenever you go to the hospital or on a trip
It is important to choose someone to make healthcare decisions for you when you cannot make or communicate decisions for yourself.
Tell the person you choose what healthcare treatments you want. e person you choose will be your agent. He or she will have the right
to make decisions for your healthcare. If you DO NOT choose someone to make decisions for you, write NONE on the line for the
agent’s name.
I, ________________________________________, SS#______________________ (optional), appoint the person named in this
document to be my agent to make my healthcare decisions.
is document is a Durable Power of Attorney for Healthcare Decisions. My agent’s power shall not end if I become incapacitated or if
there is uncertainty that I am dead. is document revokes any prior Durable Power of Attorney for Healthcare Decisions. My agent may
not appoint anyone else to make decisions for me. My agent and caregivers are protected from any claims based on following this Durable
Power of Attorney for Healthcare. My agent shall not be responsible for any costs associated with my care. I give my agent full power to
make all decisions for me about my healthcare, including the power to direct the withholding or withdrawal of life-prolonging treatment,
including artificially supplied nutrition and hydration/tube feeding. My agent is authorized to
Consent, refuse, or withdraw consent to any care, procedure, treatment, or service to diagnose, treat, or maintain a physical or mental
condition, including artificial nutrition and hydration;
Permit, refuse, or withdraw permission to participate in federally regulated research related to my condition or disorder
Make all necessary arrangements for any hospital, psychiatric treatment facility, hospice, nursing home, or other healthcare
organization; and, employ or discharge healthcare personnel (any person who is authorized or permitted by the laws of the state to
provide healthcare services) as he or she shall deem necessary for my physical, mental, or emotional well -being;
Request, receive, review, and authorize sending any information regarding my physical or mental health, or my personal affairs,
including medical and hospital records; and execute any releases that may be required to obtain such information;
Move me into or out of any State or institution;
Take legal action, if needed;
Make decisions about autopsy, tissue and organ donation, and the disposition of my body in conformity with state law; and
Become my guardian if one is needed.
In exercising this power, I expect my agent to be guided by my directions as we discussed them prior to this appointment and/or to be
guided by my Healthcare Directive (see reverse side).
If you DO NOT want the person (agent) you name to be able to do one or other of the above things, draw a line
through the statement and put your initials at the end of the line.
Agent’s name _____________________________________ Phone ____________ Email______________________________
Address______________________________________________________________________________________________
If you do not want to name an alternate, write “none.”
Alternate Agent’s name _____________________________________ Phone ____________ Email_______________________
Address______________________________________________________________________________________________
Execution and Effective Date of Appointment
My agent’s authority is effective immediately for the limited purpose of having full access to my medical records and to confer with my
healthcare providers and me about my condition. My agent’s authority to make all healthcare and related decisions for me is effective
when and only when I cannot make my own healthcare decisions.
SIGN HERE for the Durable Power of Attorney and/or Healthcare Directive forms. Many states require notarization. It is recommended for the
residents of all states. Please ask two persons to witness your signature who are not related to you or financially connected to your estate.
Signature ________________________________________________________________________________ Date___________________
Witness_________________________________________ Date _________ Witness________________________________ Date________
Notarization:
On this _____ day of______________ , in the year of ______, personally appeared before me the person signing, known by me to be the person who
completed this document and acknowledged it as his/her free act and deed. IN WITNESS WHEREOF, I have set my hand and affixed my official
seal in the County of_______________________ , State of _____________________, on the date written above.
Notary Public_________________________________________________
Commission Expires____________________________________________
This form may be photocopied and distributed Revised Oct. 2006
Page 1/2
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