Statutory Form Durable Power of Attorney for Health Care - Rhode Island

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as my attorney in fact (agent) to make any 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 and mental 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.
3. GENERAL STATEMENT OF AUTHORITY GRANTED
Subject to any limitations in this document, I hereby grant to 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 and informing my family or
next of kin of my desire, if any, to be an organ or tissue donor.
(If you want to limit the authority of your agent to make health care decisions for you, you can
state the limitations in paragraph 4 (“Statement of Desires, Special Provisions, and Limitations”)
below. You can indicate your desires by including a statement of your desires in the same
paragraph.
4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS
(Your agent must make health care decisions that are consistent with your known desires. You
can, but are not required to, state your desires in the space provided below. You should consider
whether you want to include a statement of your desires concerning life-prolonging care,
treatment, services, and procedures. You can also include a statement of your desires concerning
other matters relating to your health care. You can also make your desires known to your agent
by discussing your desires with your agent or by some other means. If there are any types of
treatment that you do not want to be used, you should state them in the space below. If you want
to limit in any other way the authority given your agent by this document, you should state the
limits in the space below. If you do not state any limits, your agent will have broad powers to
make health care decisions for you, except to the extent that there are limits provided by law.)
In exercising the authority under this durable power of attorney for health care, my agent shall act
consistently with my desires as stated below and is subject to the special provisions and limitations
stated below;
(a) Statement of desires concerning life-prolonging care, treatment, services and
procedures:
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Statutory Form Durable Power of Attorney for Health Care - Rhode Island PDF

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