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OF ATTORNEY FOR
_____________________________________________________________________ , am of
sound mind, and I voluntarily (Print or type your full name) make this
, my (insert name of patient advocate)
(Spouse, child, friend
_______________________________________________________________as my patient
My patient advocate or
successor patient advocate shall have
power to make care, custody and medical treatment decisions for me in
the event I become unable to participate in medical treatment decisions. I
understand my patient advocate must sign an acceptance before he or she
can act. I have discussed this appointment with the individual or individuals I
The determination of when I am
unable to participate in medical treatment decisions shall be made by my
attending physician and another physician or licensed psychologist.
In making decisions for me, my
patient advocate shall endeavor to follow my previously expressed wishes,
whether I have stated them orally, in a living will, or in this designation.
My patient advocate has
authority to consent to or refuse treatment on my behalf, to arrange medical and
personal services for me, including admission to a hospital or nursing care
facility, and to pay for such services with my funds.
My patient advocate shall have
access to any of my medical records to which I have a right.
REGARDING LIFE-SUSTAINING TREATMENT, OPTIONAL
I expressly authorize my patient advocate to make decisions to
withhold or withdraw