Power of Attorney for Health Care THIS POWER OF ATTORNEY REVOKES ALL PREVIOUS POWERS OF ATTORNEY FOR HEALTH CARE Name First Last Address I WANT THE FOLLOWING PERSON TO BE MY HEALTH CARE AGENT (an agent is your personal representative under state and federal law): Name First Last Address PhonePlease check box if applicable: If a guardian of my person is to be appointed. I nominate the agent acting under this power of attorney as guardian. MY AGENT CAN MAKE HEALTH CARE DECISIONS FOR ME, INCLUDING: My Agent Can Take Health Care Decisions For Me, Including: Deciding to accept, withdraw, or decline treatment for any physical or mental condition of mine, including life-and-death decisions. Agreeing to admit me to or discharge me from any hospital, home, or other institution, including a mental health facility. Having complete access to my medical and mental health records, and sharing them with others as needed, including after I die. Carrying out the plans I have already made, or, if I have not done so, making decisions about my body or remains, including organ, tissue, or whole body donation, autopsy, cremation, and burial. I Authorize My Agent To: (Please check only one box. If no box is checked, or if more than one box is checked, the directive in the first box below shall be implemented.) Make decisions for me only when I cannot make them for myself. The physician(s) taking care of me will determine when I lack this ability. Make decisions for me only when I cannot make them for myself. The physician(s) taking care of me will determine when I lack this ability. Starting now, for the purpose of assisting me with my health care plans and decisions, my agent shall have complete access to my medical and mental health records, the authority to share them with others as needed, and the complete ability to communicate with my personal physician(s) and other health care providers, including the ability to require an opinion of my physician as to whether I lack the ability to make decisions for myself. Make decisions for me starting now and continuing afrer I am no longer able to make them for myself. While I am still able to make my own decisions, I can still do so if I want to. The subject of life-sustaining treatment is of particular importance. Life-sustaining treatments may include tube feedings or fluids through a tube, breathing machines, and CPR. In general, in making decisions concerning life-sustaining treatment. your agent is instructed to consider the relief of suffering, the quality as well as the possible extension of your life, and your previously expressed 'ishes. Your agent will weigh the burdens versus benefits of proposed treatments in making decisions on your behalf. Additional statements concerning the withholding or removal of life-sustaining treatment are described below. These can serve as a guide for your agent when making decisions for you. Ask your physician or health care provider i f you have any questions about these statements. SELECT ONLY ONE STATEMENT BELOW THAT BEST EXPRESSES YOUR WISHES (optional): The quality of my life is more important than the length of my life. If I am unconscious and my attending physician believes. in accordance with reasonable medical standards, that I u'iI1 not wake up or recover my ability to think, communicate with my family and friends, and experience my surroundings, I do not want treatments to prolong my life or delay my death, but I do u ant treatment or care to make me comfortable and to relieve me of pain. Staying alive is more important to me, no matter how sick I am, how much 1 am suffering, the cost of the procedures, or how unlikely my chances for recovery are. I want my life to be prolonged to the greatest extent possible in accordance with reasonable medical standards. Specific Limitations To My Agent's Decisions-Making Authority The above grant of power is intended to be as broad as possible so that your agent will have the authority to make any decision you could make to obtain or terminate any type of health care. If you wish to limit the scope of your agent's powers or prescribe special rules or limit the power to authorize autopsy or dispose of remains, you may do so specifically on the lines below or add another page if needed: Specific Limitations To My Agent's Decision Making Authority :YOU MUST SIGN THIS FORM AND A WITNESS MUST SIGN IT BEFORE IT IS VALID My signature:Today's date Have Your Witness Agree To What Is Written Below And Then Complete The Signature Portion :I'm atleast 18 years old (Check one of the options below) I saw the principal sign this document or The principal told me that the signature or mark on the principal signature line is his or hers Witness name First Last Witness address Witness signatureToday's date Successor Health Care Agent(s) (optional): If the agent I selected is unable or does not want to make health care decisions for me, then I request the person(s) I name below to be my successor health care agent(s). Only one person at a time can serve as my agent (add another page if you want to add more successor agent names).(Successor agent #1 name, address and phone number)(Successor agent #2 name, address and phone number)
