appoint: Name: ____________________________

Address: __________________________________

Phone: __________________________________
as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. This Medical Power of Attorney takes effect if I become unable to make my own health care decisions and my physician certifies this fact in writing.

LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS:

__________________________________________________________

__________________________________________________________

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Designation of Alternate Agent

(You are not required to designate an alternate agent but you may do so. An alternate agent may make the same health care decisions as the designated agent if the designated agent is unable or unwilling to act as your agent. If the agent designated is your spouse, the designation is automatically revoked by law if your marriage is dissolved.)

If the person designated as my agent is unable or unwilling to make health care decisions for me, I designate the following persons to serve as my agent to make health care decisions for me as authorized by this document, who serve in the following order:

First Alternate Agent

Name: _______________________________

Address: _____________________________

Phone: _______________________________

Second Alternate Agent

Name: _______________________________

Address: _____________________________

Phone: _______________________________

The original of this document is kept at ________________________________________

The following individuals or institutions have signed copies:

Name: ________________________________

Address: ______________________________

Phone: _______________________________

Name: ________________________________

Address: ______________________________

Phone: _______________________________

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Duration

I understand that this power of attorney exists indefinitely from the date I execute this document unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent continues to exist until the time I become able to make health care decisions for myself.

(IF APPLICABLE) This power of attorney ends on
the following date: _________________________

Prior Designations Revoked

I revoke any prior Medical Power of Attorney.

Acknowledgment of Disclosure Statement

I have been provided with a disclosure statement explaining the effect of this document. I have read and understand that information contained in the disclosure statement.

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(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)

I sign my name to this Medical Power of Attorney on

_______ day of ___________ month ________ year

at _______________________________________.
(City and State)

_________________________________________
(Signature)

_________________________________________
(Print Name)

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Statement of Witness

I am not the person appointed an agent by this document. I am not related to the principal by blood or marriage. I would not be entitled to any portion of the principal's estate on the principal's death. I am not the attending physician of the principal or an employee of the attending physician. I have no claim against any portion of the principal's estate on the principal's death. Furthermore, if I am an employee of a health care facility in which the principal is a patient, I am not involved in providing direct patient care to the principal and am not an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility.

Signature: ________________________

Print Name: _____________________________

Address: ________________________________

Date: __________________________________

Signature: ________________________

Print Name: _____________________________

Address: ________________________________

Date: __________________________________