Durable Power of Attorney for Healthcare Decisions

**********THIS DOCUMENT IS ONLY A SAMPLE**********

IT MAY NOT CONFORM TO THE LAWS IN YOUR STATE

 
This is a Durable Power of Attorney for Healthcare Decisions, and 
the authority of my agent shall not terminate if I become 
incapacitated.  I grant to my agent full authority to make 
decisions for me regarding my healthcare.  In exercising this 
authority, my agent shall follow my desires as stated in my Health 
Care Treatment Directive or otherwise known to my agent.  My 
agent's authority to interpret my desires is intended to be as 
broad as possible and any expenses incurred should be paid by my 
resources.  My agent may not delegate the authority to make 
decisions.  My agent is authorized as follows to: 

IF THERE IS A STATEMENT IN PARAGRAPHS 1 THROUGH 6 BELOW WITH WHICH 
YOU DO NOT AGREE, DRAW A LINE THROUGH IT AND ADD YOUR INITIALS.  

1.  Consent, refuse, or withdraw consent to any care, treatment, 
service or procedure, (including artificially supplied nutrition 
and/or hydration/tube feeding) used to maintain, diagnose or treat 
a physical or mental condition; 

2.  Make decisions regarding organ donation, autopsy, and the 
disposition of my body; 

3.  Make all necessary arrangements for any hospital, psychiatric 
hospital, or psychiatric treatment facility, hospice, nursing home, 
or similar institution; to employ or discharge healthcare 
personnel (any person who is licensed, certified, or otherwise 
authorized or permitted by the laws of the state to administer 
healthcare) as the agent shall deem necessary for my physical, 
mental, and emotional well being; 

4.  Request, receive, and review any information, verbal or written, 
regarding my personal affairs or physical or mental health including 
medical and hospital records and to execute any releases of other 
documents that may be required in order to obtain such information; 

5.  Move me into or out of any state or facility for the purpose of 
complying with my Healthcare Treatment Directive or the decisions 
of my agent; 

6.  Take any legal action reasonably necessary to do what I have 
directed.  

I appoint the following person to be my agent to make healthcare 
decisions for me WHEN AND ONLY WHEN I lack the capacity to make or 
communicate a choice regarding a particular healthcare decision 
and my Healthcare Treatment Directive does not adequately cover 
circumstances.  I request that the person serving as my agent be my 
guardian if one is needed.  


Agent's Name ________________________Telephone_________________ 

Address:_______________________________________________________ 

        _______________________________________________________ 

If my agent is not available or not willing to make healthcare 
decisions for me or, if my agent is my spouse and is legally 
separated or divorced from me, I appoint the person or persons named 
below (in the order named if more than one listed) as my agent: (It 
is not necessary to name an alternate agent.) 

First Alternate Agent              Second Alternate Agent 

Name:__________________________    Name:___________________________ 

Address:_______________________    Address:________________________ 

_______________________________    ________________________________ 

Telephone:_____________________    Telephone:______________________ 

Protection of Persons Who Act as My Agent:  I and my estate hold 
my agent and my caregivers harmless and protect them against any 
claim for following this durable power of attorney.  
Severability:  If any part of this document is held to be 
unenforceable under law, I direct that all of the other provisions 
of the document shall remain in force and effect.  

Date:___________  X Signature___________________________________ 

Witness______________________________________Date_________________ 

Witness______________________________________Date_________________ 

Notarization 

Notarization of the Durable Power of Attorney is required in some 
states (e.g., Missouri but not Kansas).  If this document is both 
witnessed and notarized, it is more likely to be honored in other 
states.  

On this _______day of __________________. 200__, before me 
personally appeared the aforesaid declarant, to me known to be the 
person described in and who executed the foregoing instrument and 
acknowledged that he/she executed the same as his/her free act and 
deed.  IN WITNESS WHEREOF, I have hereunto set my hand and affixed 
my official seal in the County of _________________, State of 
________________________, the day and year first above written.  

_________________________________ ______________________________ 
Notary Public                     My Commission Expires 

Acceptance: (Optional) I have discussed this document with the 
person making this durable power of attorney and I accept the 
responsibility designated to me as stated above.  

Date_________________   Agent___________________________________