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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
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 care.
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
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, (your name)__________________________________________________________________
(your phone number)____________________________________________________________
do hereby designate and appoint:
Insert information 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.
(Name of agent)________________________________________________________________
(address of agent)_______________________________________________________________
(phone number(s) of agent)_______________________________________________________