Health Care Power of Attorney Form - Delaware

Advance Health Care Directive of ________________________________________________________ Page 4
PART II: POWER OF ATTORNEY FOR HEALTH CARE
Your ag ent m ay make any health car e decision that you could have made while you had
the capacity to make health care decisions. You may appoint an alternate agent to make
health care decisions for you if your first agent is not willing, able and reasonably available to
make decisions for you. Unless the persons you name as agent and alternate agent are
related to you by blood, neither may own, operate or be employed by any residential long-term
care inst it ution where you are receiving car e.
If you wish to appoint an agent to make health care decisions for you under these
circumstances and conditions, you must fill out the section below. You may cross out any
wording you do not want.
A. DESIGNATION OF AGENT: I desig nat e _____________________________________
as my agent to make health care decisions for me. If he/she is not living, willing or able, or
reasonably available, to make health care decisions for me, then I designate ________
________________________ as my agent t o make healt h car e decisions for m e.
___________________________________________________________________________
(name of i ndi vi dual you choos e as agent )
___________________________________________________________________________
(address) (city) (state) (zip code)
___________________________________________________________________________
(home phone) (work phone)
___________________________________________________________________________
(name of i ndi vi dual you choos e as alternat e agent)
___________________________________________________________________________
(address) (city) (state) (zip code)
___________________________________________________________________________
(home phone) (work phone)
B. AGENT’S AUTHORITY: I grant to my agent full authority to make decisions for me
regarding my health care; provided that, in exercising this authority, my agent shall follow my
desires as stated in this document or otherwise known to my agent. Accordingly, my agent is
author ized as follows:
1. To consent to, refuse, or withdraw consent to any and all types of medical care,
treatment, surgical procedures, diagnostic procedures, medication, and the use of mechanical
or ot her pr ocedur es that affect any bodily function;
2. To have access to medical records and information to the same extent that I am
entit led t o, including t he r ight t o disclose the cont ent s t o other s;
3. To authorize my admission to or discharge from any hospital, nursing home,
resident ial car e , assisted living or similar facilit y or service;
4. To contract for any health care related service or facility on my behalf, without my
agent incur r ing per sonal financial liability f or such cont r a ct s;
5. To hire and fire medical, social service, and other support personnel responsible for
my care; and
Page 4/6
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Health Care Power of Attorney Form - Delaware PDF

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