THIS IS WHAT I WANT MY HEALTH CARE AGENT
TO BE ABLE TO DO IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF
(I know I can change these choices)
My health care agent is automatically given the powers listed below in (A) through (D). My health care
agent must follow my health care instructions in this document or any other instructions I have given
to my agent. If I have not given health care instructions, then my agent must act in my best interest.
Whenever I am unable to decide or speak for myself, my health care agent has the power to:
(A) Make any health care decision for me. This includes the power to give, refuse, or withdraw
consent to any care, treatment, service, or procedures. This includes deciding whether to stop
or not start health care that is keeping me or might keep me alive, and deciding about intrusive
mental health treatment.
(B) Choose my health care providers .
Choose where I live and receive care and support when those choices relate to my health care
Review my medical records and have the same r ights that I would have to give my
medical records to other people.
If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR if I want to
LIMIT any power in (A) through (D), I MUST say that here: ___________________________________________________
My health care agent is NOT automatically given the powers listed below in (1) and (2). If I WANT my
agent to have any of the powers in ( 1) and (2), I must INITIAL the line in front of the power; then my
agent WILL HAVE that power .
To decide whether to donate any parts of my body, including organs, tissues, and eyes,
when I die.
(2) To decide what will happen with my body when I die (burial, cremation).
If I wa nt to say anything more about my health care agent's powers or limits on the powers, I can say it