(b) Additional statement of desires, special provisions, and
limitations regarding health care decisions:
(c) Statement of desire regarding organ and tissue donation:
Initial if applicable:
[ ] In the event of my death, I request that my agent inform my
family/next of kin of my desire to be an organ and tissue donor, if
(You may attach additional pages if you need more space to
complete your statement. If you attach additional pages, you must
date and sign EACH of the additional pages at the same time you date
and sign this document.)
(5) INSPECTION AND DISCLOSURE OF INFORMATION RELATING
TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in
this document, my agent has the power and authority to do all of the
(a) Request, review, and receive any information, verbal or written,
regarding my physical or mental health, including, but not limited to,
medical and hospital records.
(b) Execute on my behalf any releases or other documents that may
be required in order to obtain this information.
(c) Consent to the disclosure of this information.
(If you want to limit the authority of your agent to receive and
disclose information relating to your health, you must state the
limitations in paragraph (4) ("Statement of desires, special provisions,
and limitations") above.)
(6) SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where
necessary to implement the health care decisions that my agent is
authorized by this document to make, my agent has the power and
authority to execute on my behalf all of the following:
(a) Documents titled or purporting to be a "Refusal to Permit
Treatment" and "Leaving Hospital Against Medical Advice."