POWER OF ATTORNEY – HEALTH CARE
(Note: Rules regarding legal sufficiency of a power of attorney vary by state. Please consult your state rules and have the form reviewed by a lawyer in your state regarding additional language, witness signatures, and notary requirements.)
1. I, [INSERT NAME and ADDRESS] the undersigned hereby make, constitute and appoint [INSERT NAME and ADDRESS] as my health care attorney-in-fact to act for me in my name to make health care decisions for me. My attorney-in-fact will have full authority to make health care decisions for me in the future, if and when I do not have the mental capacity to make my own health care decisions.
2. This Power of Attorney is effective upon and only during, any period of mental incompetence. Any time while I am competent, I may revoke this power of attorney by communicating my intent to revoke to my health care attorney-in-fact or health care provider.
3. My attorney-in-fact will make a good faith effort to discuss the proposed decision with me to determine my desires in making my decision. If my attorney-in-fact cannot determine my desires, then my attorney-in-fact may make a choice for me based upon what my attorney-in-fact believes to be in my best interests. Accordingly, my attorney-in-fact’s authority to interpret my desires is intended to be as broad as possible. These decisions include, but are not limited to:
[INSERT ANY GENERAL STATEMENT OF AUTHORITY GRANTED: SIGNING/EXECUTING DOCUMENTS, AUTHORITY TO EMPLOY OR DISCHARGE HEALTH CARE PROVIDER, AUTHORITY TO CONSENT TO ADMISSION /DISCHARGE FROM HOSPITAL, AUTHORITY TO CONSENT TO MEDICAL PROCEDURES/TEST, ETC.]
4. Special Provisions
[INSERT ANY PROVISIONS REGARDING ORGAN DONATION, GUARDIANSHIP PROVISION, ARTIFICIAL FEEDING/HYDRATION, MENTAL HEALTH DECISIONS, MENTAL HEALTH TREATMENT, AUTOPSY AND DISPOSITION OF REMAINS]
5. Miscellaneous Provisions
[INSERT ANY REIMBURSEMENT PROVISION, LIABILITY PROVISION, SEVERABILITY PROVISION]
6. This Power of Attorney shall be governed by the State of [INSERT STATE].
Signed this __________ day of ______________________, __________.
________________________________________
(Your signature)
________________________________________
(Your Social Security number)
State of ________________________, County of _________________________, USA