Power of Attorney for Health Care Will to Live Form - Idaho

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Idaho Durable Power of Attorney for Health Care
Will to Live Form
1. DESIGNATION OF HEALTH CARE AGENT
I, (your name)__________________________________________________________________
(your address)__________________________________________________________________
_____________________________________________________________________________
(your phone number)____________________________________________________________
do hereby designate and appoint:
(Name of agent)________________________________________________________________
(address of agent)_______________________________________________________________
(phone number(s) of agent)_______________________________________________________
(insert name, address and telephone number(s) of one individual only as your agent to make
health care decisions for you. None of the following may be designated as your agent: (1) your
treating health care provider; (2) a non-relative employee of your treating health care provider;
(3) an operator of a community care facility; or (4) a non-relative employee of an operator of a
community care facility.)
as my attorney-in-fact (agent) to make health care decisions for me as authorized in this
document. For the purposes of this document, “health care decision” means consent, refusal of
consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain,
diagnose, or treat an individual’s physical condition.
2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE
By this document I intend to create a durable power of attorney for health care. This power of
attorney shall not be affected by my subsequent incapacity.
3. GENERAL STATEMENT OF AUTHORITY GRANTED
Subject to any limitations in this document, I hereby grant my agent full power and authority to
make health care decisions for me to the same extent that I could make such decisions for myself
if I had the capacity to do so. In exercising this authority, my agent shall make health care
decisions that are consistent with my desires as stated in this document or otherwise made known
to my agent, including, but not limited to, my desires concerning obtaining or refusing or
withdrawing life-prolonging care, treatment, services, and procedures. (If you want to limit the
authority of your agent to make health care decisions for you, you can state the limitations in
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Power of Attorney for Health Care Will to Live Form - Idaho PDF

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