Durable Power of Attorney for Health Care

If I should be incompetent or in a state of persistent unconscious, I want to designate another person as my representative to make the types of decisions checked below. All decisions should be made exactly as I would make them if I were capable. My representative is authorized to:

Authorize my admission to a medical, nursing, residential or similar facility and enter into agreement for my care.

Authorize medical and surgical procedures.

Authorize withholding or withdrawing life-sustaining treatment.

Make all other medical treatment decisions.

I do not want to designate another person as my representative if I should be incompetent and in a terminal condition or in a state or persistent unconsciousness.

PLEASE NOTE: The Power of Attorney for Health Care has the authority to make organ donation decisions.

Name, address and phone number of representative (if applicable):
_________________________________________
_________________________________________
_________________________________________.

I made this declaration on the _____ day of ____________, 20 ___.

Declarant's signature:

_________________________________________

Declarant's address:

_________________________________________

Declarant's phone:

_________________________________________

The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence.

Witness's signature:

_________________________________________

Witness's address:

_________________________________________

Witness's phone:

_________________________________________

Witness's signature:

_________________________________________

Witness's address:

_________________________________________

Witness's phone:

_________________________________________

Source: Saint Vincent Health Center, Erie

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