Healthcare Power of Attorney

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HEALTH CARE POWER OF ATTORNEY

1. DESIGNATION OF HEALTH CARE AGENT

I, ___________________________________________________, (_____/____/_____)

(Principal)

(Social Security Number)

hereby appoint: ______________________________

                          (Agent)

______________________________________________________________________

(Address)

______________________________________________________________________

Home Telephone: _____________ Work Telephone: ______________ as my agent to make health care decision for me as authorized in this document. 

2. EFFECTIVE DATE AND DURABILITY

By this document I intend to create a durable power of attorney effective upon, and only during, any period of mental incompetence. 

3. AGENT'S POWERS

I grant to my agent full authority to make decisions for me regarding my health care. In exercising this authority, my agent shall follow my desires as stated in this document or otherwise expressed by me or known to my agent. In making any decision, my agent shall attempt to discuss the proposed decision with me to determine my desires if I am able to communicate in any way. If my agent cannot determine the choice I would want made, then my agent shall make a choice for me based upon what my agent believes to be in my best interests. 

My agent's authority to interpret my desire is intended to be as broad as possible, except for any limitations I may state below. Accordingly, unless specifically limited by Section E. below, my agent is authorized as follows: 

A.

To consent, refuse, or withdraw consent to any and all types of medical care, treatment, surgical procedures, diagnostic procedures, medication, and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, nutritional support and hydration, and cardiopulmonary resuscitation;

B.

To authorize, or refuse to authorize, any medication or procedure intended to relieve pain, even though such use may lead to physical damage, addiction, or hasten the moment of, but not intentionally cause, my death;

C.