Statutory and Durable Health Care Power of Attorney - Rhode Island

(b) Any necessary waiver or release from liability required by a
hospital or physician.
(7) DURATION. (Unless you specify a shorter period in the space
below, this power of attorney will exist until it is revoked.)
This durable power of attorney for health care expires on
(Fill in this space ONLY if you want the authority of your agent to
end on a speci7c date.)
(8) DESIGNATION OF ALTERNATE AGENTS.
(You are not required to designate any alternate agents but you may
do so. Any alternate agent you designate will be able to make the
same health care decisions as the agent you designated in paragraph
(1), above, in the event that agent is unable or ineligible to act as your
agent. If the agent you designated is your spouse, he or she becomes
ineligible to act as your agent if your marriage is dissolved.)
If the person designated as my agent in paragraph (1) is not
available or becomes ineligible to act as my agent to make a health
care decision for me or loses the mental capacity to make health care
decisions for me, or if I revoke that person's appointment or authority
to act as my agent to make health care decisions for me, then I
designate and appoint the following persons to serve as my agent to
make health care decisions for me as authorized in this document,
such persons to serve in the order listed below:
(A) First Alternate Agent:
(Insert name, address, and telephone number of 7rst alternate
agent.)
(B) Second Alternate Agent:
(Insert name, address, and telephone number of second alternate
agent.)
(9) PRIOR DESIGNATIONS REVOKED. I revoke any prior durable
power of attorney for health care.
DATE AND SIGNATURE OF PRINCIPAL
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
Page 5/7
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Statutory and Durable Health Care Power of Attorney - Rhode Island DOC

Statutory and Durable Health Care Power of Attorney - Rhode Island PDF

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