Fill and Sign the Section 133717 Printed Form Durable Power of Attorney

DURABLE POWER OF ATTORNEY FOR HEALTH CARE (Ohio Revised Code 1337.11 to 1337.17) The following Notice to Adult Executing This Document (Durable Power of Attorney for Health Care) is required by Ohio Revised Code, Section 1337.17. If, after reading this notice, you still have questions concerning the effect and legal consequences of executing this document, you should speak with a qualified attorney. NOTICE TO ADULT EXECUTING THIS DOCUMENT This is an important legal document. Before executing this document, you should know these facts: This document gives the person you designate (the attorney in fact) the power to make MOST health care decisions for you if you lose the capacity to make informed health care decisions for yourself. This power is effective only when your attending physician determines that you have lost the capacity to make informed health care decisions for yourself and, notwithstanding this document, as long as you have the capacity to make informed health care decisions for yourself, you retain the right to make all medical and other health care decisions for yourself. You may include specific limitations in this document on the authority of the attorney in fact to make health care decisions for you. Subject to any specific limitations you include in this document, if your attending physician determines that you have lost the capacity to make an informed decision on a health care matter, the attorney in fact GENERALLY will be authorized by this document to make health care decisions for you to the same extent as you could make those decisions yourself, if you had the capacity to do so. The authority of the attorney in fact to make health care decisions for you GENERALLY will include the authority to give informed consent, to refuse to give informed consent, or to withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
You represent that you are of sound mental and physical condition. This form and instructions are a legal document. If it appears from this form and instructions that you have questions that are not answered by this document, please consult a qualified health care professional. This is not a legally binding document, and you have no legal or contractual responsibility to your appointing physician for the use, interpretation, performance, and care of this document. This should not be relied upon in any way as an admission or representations of your health care rights. You should not rely upon the validity or enforceability of this document as a substitute for a legally executed or properly executed durable power of attorney. You may not use this document for the purpose of avoiding the consequences of a breach of medical practice; for example, if you do not provide a durable power of attorney but use an retained power of attorney (or a power of attorney for health care but fail to include in the document your name or the name of your attorney) and your attending physician decides to perform a particular operation on you without your consent, you have no legal obligation to you, as a matter of law, that you be responsible to pay for that operation. This is not a substitute for a valid medical release form. If you are a minor, the provisions of this document may be different from provisions of your parental or guardian medical release form. You represent and warrant that you are not making any statement, representation, or warranty hereunder, and you fully understand and accept the risks of reliance upon the advice and statements contained in this document. This may include your refusal to provide information related to any treatment, procedure, or other treatment to which you are or will be subjected. This does not limit or expand the right to be informed in any manner regarding your care, treatment, services, privileges and limitations. There are certain circumstances under which you may waive, in writing, the provision for you or your minor child of a durable power of attorney and/or the provisions of this document. Your power of attorney includes, but is not limited to, the following, which will only be permitted to be waived: a copy of the written waiver executed or executed by your parent or guardian (in this case, the provisions of the legal document will not be waived as long as your parent or guardian executed the waiver before the minor.