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ADVANCE HEALTH CARE DIRECTIVE
MY NAME IS
.
PART 1: HEALTH CARE POWER OF
ATTORNEY
DESIGNATION OF AGENT:
I designate the following individual
as my agent to make health care decisions for me:
(Name and relationship of individual
designated as health care agent)
(Address) (City) (State)
(Zip code) (Home phone) (Work phone) (E-Mail)
If I revoke my agent’s authority or
if my agent is not willing, able, or reasonably available to make decisions for
me, I designate the following individual as my alternate agent:
(Name and relationship of individual
designated as alternate health care agent)
(Address) (City) (State)
(Zip code) (Home phone) (Work phone) (E-Mail)
WHEN AGENT'S AUTHORITY BECOMES
EFFECTIVE:
My agent’s authority becomes
effective when my primary physician determines that I am unable to make my own
health care decisions unless I mark the following box.
____
c
If I mark this box, my agent’s authority to make health care decisions for me
takes effect immediately. However, I always retain the right to make my
own decisions about my health care and to revoke this authority as long as I am
mentally capacitated.
AGENT'S AUTHORITY AND OBLIGATION:
I intend my agent’s authority to be
as broad as possible subject only to any instructions and limitations I may
state in Part 2 of this form or as I may otherwise provide orally or in writing.
To the extent my wishes are unknown, my agent shall make health care decisions
for me in accordance with what my agent determines to be in my best interest.
In determining my best interest, my agent shall consider my personal values to
the extent known to my agent. If a guardian of my person needs to be
appointed for me by a court, I nominate my agent.
PART 2: INDIVIDUAL INSTRUCTIONS
FOR HEALTH CARE
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