except to inform your family or next of kin of your desire, if any, to be
an organ and tissue owner.
You have the right to revoke the authority of your agent by notifying
your agent or your treating doctor, hospital, or other health care
provider orally or in writing of the revocation.
Your agent has the right to examine your medical records and to
consent to their disclosure unless you limit this right in this document.
This document revokes any prior durable power of attorney for health
You should carefully read and follow the witnessing procedure
described at the end of this form. This document will not be valid
unless you comply with the witnessing procedure.
If there is anything in this document that you do not understand, you
should ask a lawyer to explain it to you.
Your agent may need this document immediately in case of an
emergency that requires a decision concerning your health care.
Either keep this document where it is immediately available to your
agent and alternate agents or give each of them an executed copy of
this document. You may also want to give your doctor an executed
copy of this document.
(1) DESIGNATION OF HEALTH CARE AGENT. I,
(insert your name and address)
do hereby designate and appoint:
(Insert name, address, and telephone number 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 nonrelative employee of your treating health care
provider, (3) an operator of a community care facility, or (4) a
nonrelative 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 or mental