This Health Care Power of Attorney form allows an individual to grant someone they trust the authority to make health care decisions on their behalf in the event that they become incapacitated in some way so that they are unable to make those decisions themselves.
Health Care Power of Attorney
_______________________, hereinafter referred to as PRINCIPAL, whose address, ___________________, _____ (City), _______________ (State), being of sound mind, desire to appoint ______________, of __________________(Address) of _______________ County, ______________ as my true and lawful attorney-in-fact.
This durable power of attorney shall become effective upon the disability or incapacity of the principal.
In the principal's name, and for the principal's use and benefit, said attorney-in-fact is authorized hereby:
1. To consent to the administration of pain-relieving drugs or treatment or procedures (including surgery) that my agent, upon medical advice, believes may provide comfort to me, even though such drugs, treatment or procedures may hasten my death. My comfort and freedom from pain are important to me and should be protected by my agent and physician.
2. If I am in a terminal condition, to give, to withdraw or to refuse to give informed consent to life-sustaining treatment, including artificially or technologically supplied nutrition or hydration.
3. To give, withdraw or refuse to give informed consent to any health care procedure, treatment, intervention or other measure.
4. To request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, all my medical and health care records.
5. To execute for me any releases or other documents that may be required in order to obtain medical and related information.
6. To execute consents, waivers, and releases of liability for me and for my estate to all persons who comply with my agentís instructions and decisions. To indemnify and hold harmless, at my expense, any third party who acts under this Health Care Power of Attorney. I will be bound by such indemnity entered into by my agent.
7. To complete and sign for me the following:
(a) Consents to health care treatment, or the issuance of Do Not Resuscitate (DNR) Orders or other similar orders; and
(b) Requests for my transfer to another facility, to be discharged against health care advice, or other similar requests; and
(c) Any other document desirable to implement health care decisions that my agent is authorized to make pursuant to this document.
I understand the purpose and effect of this document and sign my name to this Health
Care Power of Attorney on ____________________, 20 _______, at _____________________.
Signature of Principal
Witness 1††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Date
Witness 2††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Date