Fill and Sign the Colorado Medical Power Form

MEDICAL DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS I. APPOINTMENT OF AGENT AND ALTERNATES I, _________________________, Declarant, hereby appoint: Name of Agent _________________________ Agent’s Best Contact Telephone Number _________________________ Agent’s email or alternative telephone number _________________________ Agent’s home address _________________________ as my Agent to make and communicate my healthcare decisions when I cannot. This gives my Agent the power to consent to, or refuse, or stop any healthcare, treatment, service, or diagnostic procedure. My Agent also has the authority to talk with healthcare personnel, get information, and sign forms as necessary to carry out those decisions. If the person named above is not available or is unable to continue as my Agent, then I appoint the following person(s) to serve in the order listed below. Name of Alternate Agent #1 _________________________ Agent’s Best Contact Telephone Number _________________________ Agent’s email or alternative telephone number _________________________ Agent’s home address _________________________ Name of Alternate Agent #2 _________________________ Agent’s Best Contact Telephone Number _________________________ Agent’s email or alternative telephone number _________________________ Agent’s home address _________________________ II. WHEN AGENT’S POWERS BEGIN By this document, I intend to create a Medical Durable Power of Attorney which shall take effect either (initial one ): ______ ( Initials) Immediately upon my signature. ______ (Initials) When my physician or other qualified medical professional has determined that I am unable to make my or express my own decisions, and for as long as I am unable to make or express my own decisions. III. INSTRUCTIONS TO AGENT My Agent shall make healthcare decisions as I direct below, or as I make known to him or her in some other way. If I have not expressed a choice about the decision or healthcare in question, my Agent shall base his or her decisions on what he or she, in consultation with my healthcare providers, determines is in my best interest. I also request that my Agent, to the extent possible, consult me on the decisions and make every effort to enable my understanding and find out my preferences. State here any desires concerning life-sustaining procedures, treatment, general care and services, including any special provisions or limitations: _________________________ My signature below indicates that I understand the purpose and effect of this document: ________________________________ _________________ Signature of Declarant Date Pursuant to Colorado Revised Statute 15-14.506 ADDENDUM TO MEDICAL DURABLE POWER OF ATTORNEY – RECOMMENDED, NOT REQUIRED 1. Signature of the Appointed Agent Although not required by Colorado law, my signature below indicates that I have been informed of my appointment as a Healthcare Agent under Medical Durable Power of Attorney for _________________________ (name of Declarant). I accept the responsibilities of that appointment, and I have discussed with the Declarant his or her wishes and preferences for medical care in the event that he or she cannot speak for him-or herself. I understand that I am always to act in accordance with his or her wishes, not my own, and that I have full authority to speak with his or her healthcare providers, examine healthcare records, and sign documents in order to carry out those wishes. I also understand that my authority as a Healthcare Agent is only in effect when the Declarant is unable to make his or her own decisions and that it automatically expires at his or her death. If I am an alternate Agent, I understand that my responsibilities and powers will only take effect if the primary Agent is unable or unwilling to serve. _______________________________________ Primary Agent’s Signature_________________________ Printed Name_________________________ Date _________________________________ Alternate Agent #1 Signature_________________________ Printed Name_________________________ Date _________________________________ Alternate Agent #2 Signature_________________________ Printed Name_________________________ Date 2. Signature of Witnesses and Notary The signature of two witnesses and a notary seal are not required by Colorado law for proper execution of a Medical Durable Power of Attorney; however, they may make the document more acceptable in other states. This document was signed by _________________________ (name of Declarant) in our presence, and we, in the presence of each other, and at the Declarant’s request, have signed our names below as witnesses. We declare that, at the time the Declarant signed this document, we believe that he or she was of sound mind and under no pressure or undue influence. We are at least eighteen (18) years old. ____________________________________ Signature of Witness_________________________ Printed Name_________________________ Address ____________________________________ Signature of Witness_________________________ Printed Name_________________________ Address Notary Seal (optional) State of Colorado County of _________________________ } SUBSCRIBED and sworn to before me by _________________________, the Declarant, and _________________________ and _________________________, witnesses, as the voluntary act and deed of the Declarant this ______ day of _______________ ,20___. _________________________________________ Notary Public My commission expires: ___________________________ Pursuant to Colorado Revised Statute 15-14.506