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Name of Grantor
Address of Grantor
Name of Attorney-In-Fact
Address of Attorney-In-Fact
Name of Attorney-In-Fact Successor
Address of Attorney-In-Fact Successor


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HTML Power Of Attorney For Health Care Decisions

POWER OF ATTORNEY FOR HEALTH CARE DECISIONS

 

KNOW ALL MEN BY THESE PRESENTS, that I, _________________________________ of ________________________________________ ___________________________(the "Principal") hereby designate _______________________________, my ______________________, as my attorney in fact (“Attorney”). I hereby give to my Attorney the power to make health care decisions on behalf of me and in my name as authorized in this document.  In the event if my Attorney is unwilling or unable to serve, I further nominate ________________________________ to serve as my Attorney.

 

Except as otherwise stated in this document, my Attorney shall have full power to make health care decisions on my behalf, including to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.  My Attorney shall also have the right to examine my medical records and to consent to disclosure of such records.

 

This power of attorney may be revoked by me at any time in any manner by which I am able to communicate my intent to revoke to my health care agent and my attending physician. If not revoked, this power of attorney comes into effect only when it is certified as stated hereunder that I am unable to make those health care decisions. My incapacity shall be deemed to exist when so certified in writing by two licensed physicians not related to either me or my Attorney.  The said certificate shall state that I am unable, physically or mentally, in the judgment of said physician, to make those health care decisions for myself.

 

Notwithstanding anything to the contrary, I reserve the right to make any medical and other health care decisions for myself so long as I am able to consent with respect to a particular decision.  In addition, no treatment may be given to me over my objection, and health care necessary to keep me alive may not be stopped if I object.

 

I hereby authorize all physicians who have treated, or will treat me, and all other providers of health care, including hospitals, to release to my Attorney all information contained in my medical records which my Attorney may request whether oral or written.

 

No person who relies in good faith upon the authority or any representations by my Attorney shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions by my Attorney.

 

I revoke any prior health care power of attorney.

 

 

Signed this _____ day of _____________________, 20_________

 

______________________________________

signature

 

Witness’s signature and addresses:

 

_________________________________

signature

 

address:

_________________________________

 _________________________________

 

_________________________________

signature

 

address:

_________________________________

_________________________________

 

State of ______________________

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County of _____________________

 

 

 

On this ____ day of ______________, _____________, before me, the undersigned, a Notary Public in and for the State of ___________________, personally appeared ___________________________________ to me known to be the identical person named in and who executed the foregoing instrument, and acknowledged that he or she executed the same as his or her voluntary act and deed.

_______________________________________________________

Notary Public

 

Description

At one point in life, you may find it necessary to appoint a trusted family member or friend to make really important health care decisions for you. If you are searching for a quality legal Power of Attorney for Health care decisions form, you have come to the right site. Why pay for this form at another site, when you can save yourself the risk and get this free fillable form that you can easily download and print.







Instructions

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