THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESCENCE
OF TWO COMPETENT ADULT WITNESSES. THE FOLLOWING PERSONS MAY NOT ACT
AS ONE OF THE WITNESSES:
1) the person you have designated as your agents; 2) a person related to you by blood or marriage;
3) a person entitled to any part of your estate after your death under a will or codicil executed by you or
by operation of law; 4) your attending physician; 5) an employee of your attending physician; 6) an
employee of a healthcare facility in which you are a patient if the employee is providing direct patient
care to you or is an officer, director, partner, or business office employee of the healthcare facility or of
any parent organization of the healthcare facility; or 7) a person who, at the time this power of attorney is
executed, has a claim against any part of your estate after your death.
I have read and understood the contents of this disclosure statement.
(Signature)_______________________________________ (Date) _____________________
DESIGNATION OF HEALTHCARE AGENT
I, ________________________________________________ (insert your name) appoint:
As my agent to make any and all healthcare decisions for me, except to the extent I state
otherwise in this document. This medical power of attorney takes effect if I become unable to
make my own healthcare decisions and this fact is certified in writing by my physician.
LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS
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