1 . Designation of Healthcare Agent
I , _______________________________________________ ( insert your name ) do hereby designate and appoint : Name : ______________________________________________________________________________________________________ Address : ____________________________________________________________________________________________________ Telephone Number : __________________________________________________________________________________________ as my Attorney-In-Fact to make healthcare decisions for me as authorized in this document .
Insert the name and address of the person you wish to designate as your Attorney-In-Fact to make healthcare decisions for you . Unless the person is also your spouse , legal guardian or the person most closely related to you by blood , none of the following may be designated as your Attorney-In-Fact : ( 1 ) your treating provider of healthcare ; ( 2 ) an employee of your treating provider of healthcare ; ( 3 ) an operator of a healthcare facility ; or ( 4 ) an employee of an operator of a healthcare facility .
2 . Creation of a Durable Power of Attorney for Healthcare
By this document , I intend to create a Durable Power of Attorney by appointing the person designated above to make healthcare 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 healthcare decisions , I hereby grant to the Attorney-In-Fact named above full power and authority : to make healthcare 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 ; to request , review and receive any information , verbal or written , regarding my physical or mental health , including , without limitation , medical and hospital records ; to execute on my behalf any releases or other documents that may be required to obtain medical care and / or medical and hospital records , EXCEPT any power to enter into any arbitration agreements or execute any arbitration clauses in connection with admission to any healthcare facility including any skilled nursing facility ; and subject only to the limitations and special provisions , if any , set forth in paragraph 4 or 6 .
Form Number : 100-002 Revision Date : 4 / 2022 -3-