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State of Arkansas
Power of Attorney for Health Care
Will to Live Form
I, (your name)__________________________________________________________________
(your phone number)____________________________________________________________
(Name of agent)________________________________________________________
(Address of agent)_______________________________________________________
(Phone number(s) of agent)_______________________________________________
as my health care agent to make any health care decisions for me as authorized in this document
consistent with the instructions below.
If the person I designate above refuses or is not able to act for me, I designate the following
persons (each to act alone and successively, in the order named):
A. First Successor Agent
(Successor’s phone number)_______________________________________________________
B. Second Successor Agent
(Second successor’s name)________________________________________________________
(Second successor’s address)______________________________________________________
(Second successor agent’s phone number)____________________________________________
as my health care agent(s) to make any health care decisions for me as authorized in this
document consistent with the instructions below.
This designation shall become effective only when I become incapable of making and
communicating my own health care decisions.
Any prior designation is revoked.