Durable Power of Attorney Form

Durable Power of Attorney for Healthcare Decisions

WARNING TO PERSON EXECUTING THIS DOCUMENT

This is an important legal document. It creates a Durable Power of Attorney for Healthcare. Before executing this document, you should know these important facts:

1. This document gives the person you designate as your Agent the power to make health care decisions for you. This power is subject to any limitations or statement of your desires that you include in this document.

2. The person you designate in this document has a duty to act consistent with your desires as stated in this document or otherwise made known or, if your desires are unknown, to act in your best interests.

3. Except as you otherwise specify in this document, the Power of the person you designate to make health care decisions for you may include the power to consent to your doctor not giving treatment or stopping treatment which would keep you alive.

4. Unless you specify a shorter period in this document, this Power will exist indefinitely from the date you execute this document and if you are unable to make health care decisions for yourself, this power will continue to exist until the time when you become able to make health care decisions for yourself.

5. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision.

6. You have the right to revoke the appointment of the person designated in this document to make health care decisions for you by notifying that person of the revocation orally or in writing.

7. You have the right to revoke the authority granted to the person designated in this document to make health care decisions for you by notifying the medical physician, hospital, or other provider of health care orally or in writing.

8. The person designated in this document to make health care decisions for you has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.

9. This document revokes any prior Durable Power of Attorney for Healthcare.

10. If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.

1. DESIGNATION OF HEALTHCARE AGENT

I, do hereby designate and appoint:

Name:

Address:

Telephone Number:

2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE

By this document, I intend to create a Durable Power of Attorney by appointing the person designated above to make health care decisions for me. This Power of Attorney shall not be affected by my subsequent incapacity.

3. GENERAL STATEMENT OF AUTHORITY GRANTED

In the event that I am incapable of giving informed consent with respect to health care decisions, I hereby grant to the agent named above full power and authority to make health care decisions for me before or after my death, including consent, refusal of consent, or withdrawal of consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition.

4. SPECIAL PROVISIONS AND LIMITATIONS

In exercising the authority under this Durable Power of Attorney for healthcare, the authority of my agent is subject to the following special provisions and limitations:

5. DURATION

I understand that this Power of Attorney will exist indefinitely from the date I execute this document unless I establish a shorter time.

I wish to have this Power of Attorney end on the following date:

6. STATEMENT OF DESIRES

Initial any statement that reflects your desires:

I desire that my life be prolonged to the greatest extent possible.

If I am in an irreversible coma, I desire that life sustaining or prolonging treatments not be used.

If I have an incurable or terminal condition or illness and no reasonable hope of recovery, I desire that life-sustaining or prolonging treatments not be used.

I want to receive or continue receiving artificial nutrition and hydration after all other treatment is withheld.

I do not desire treatment to be provided and/or continue if the burdens outweigh the expected benefits.

Other or Additional Statements of Desires:

7. DESIGNATION OF ALTERNATE AGENT

First Alternative Agent

Name:

Address:

Telephone Number:

Second Alternative Agent

Name:

Address:

Telephone Number:

8. PRIOR DESIGNATIONS REVOKED

I revoke any prior Durable Power of Attorney for Healthcare.

9. WAIVER OF CONFLICT OF INTEREST

If my designated agent is my spouse or is one of my children, then I waive any conflict of interest in carrying out the provisions of this Durable Power of Attorney for Health Care.

10. CHALLENGES

If the legality of any provision of this Durable Power of Attorney for Health Care is questioned, my agent is authorized to commence an action for declaratory judgment.

11. NOMINATION OF GUARDIAN

If incompetency proceedings are initiated, I nominate my agent as my guardian or conservator for consideration by the court.

12. RELEASE OF INFORMATION

I agree to authorize and allow full release of information to my agent named herein.

13. ACKNOWLEDGEMENT / NOTARY OR WITNESSES

County: Date:

Notary Public Name:

Principal Name:

STATEMENT OF WITNESSES

Witness #1

Signature:

Print Name:

Residence Address:

Date:

Witness #2

Signature:

Print Name:

Residence Address:

Date:

Additional Witness Declaration

I declare under penalty of perjury that I am not related to the principal by blood, marriage, or adoption and that I am not entitled to any part of the estate of the principal upon death of the principal under a will now existing by operation of law.

Copies: You should retain an executed copy of this document and give one to your agent. The Power of Attorney should be available so a copy may be given to your providers of health care.