4 . Special Provisions and Limitations
Your Attorney-In-Fact is not permitted to consent to any of the following : commitment to or placement in a mental health treatment facility , convulsive treatment , psychosurgery , sterilization or abortion . If there are any other types of treatment or placement that you do not want your Attorney-In-Fact ’ s authority to give consent for or other restrictions you wish to place on the Attorney-In-Fact ’ s authority , you should list them in the space below . If you do not write any limitations , your Attorney-In-Fact will have the broad powers to make healthcare decisions on your behalf , which are set forth in paragraph 3 , except to the extent that there are limits by law .
In exercising the authority under the Durable Power of Attorney for Healthcare , the authority of my Attorney-In-Fact 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 . If I am unable to make healthcare decisions for myself when this Power of Attorney expires , the authority I have granted my Attorney-In-Fact will continue to exist until the time when I become able to make healthcare decisions for myself .
I wish to have this Power of Attorney end on the following date ( if applicable ): _____________________________________________________________________________________________________________
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