Download Health Care Power of Attorney Form for Free | Page 2

The Health Care Power of Attorney Form is a legal document that entrusts someone else to act on behalf of you to make decisions related to health care. Usually, the agent will make decisions in place of you when you are unable to do so. It is vital for you to choose a trusted agent for yourself. The agent can be your spouse, family members or even friends. In case that the agent cannot make decisions one day, you had better choose one more person as the alternative. Whoever is in need of this form can download it from our website for free.

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A Power of Attorney for My Health Care Page 3
Part 3: What Will Your Agent's Powers Be?
Part 3 gives your agent broad authority to
make all health care decisions for you.
Some states may limit your agent’s
This form gives your agent authority that is
as broad as possible, even over life and
death decisions. Some states require
physicians to certify certain diagnoses
before your agent can make some
My agent knows my goals and wishes based on our conversations
and on any other guidance I may have written. My agent has full
authority to make decisions for me about my health care
according to my goals and wishes. If the choice I would make is
unclear, then my agent will decide based on what he or she
believes to be in my best interests. My agent’s authority to
interpret my wishes is intended to be as broad as possible, and
includes the following authority:
1. To agree to, refuse, or withdraw consent to any type of
medical care, treatment, surgical procedures, tests, or
medications. This includes decisions about using
mechanical or other procedures that affect any bodily
function, such as artificial respiration, artificially
supplied nutrition and hydration (that is, tube feeding),
cardiopulmonary resuscitation, or other forms of
medical support, even if deciding to stop or withhold
treatment could or would result in my death;
2. To have access to medical records and information to the
same extent that I am entitled to, including the right to
disclose health information to others;
3. To authorize my admission to or discharge (even against
medical advice) from any hospital, nursing home, residential
care, assisted-living or similar facility or service;
4. To contract for any health care-related service or facility for
me, or apply for public or private health care benefits, with the
understanding that my agent is not personally financially
responsible for those contracts;
5. To hire and fire medical, social service, and other support
personnel who are responsible for my care;
6. To authorize my participation in medical research related to
my medical condition;
7. To agree to or refuse using any medication or procedure
intended to relieve pain or discomfort, even though that use
may lead to physical damage or dependence or hasten (but
not intentionally cause) my death;
8. To decide about organ and tissue donations, autopsy, and the
disposition of my remains as the law permits;
9. To take any other action necessary to do what I authorize
here, including signing waivers or other documents, pursuing
any dispute resolution process, or taking legal action in my
This first power is very
important. To clearly confirm
your agent’s authority over
decisions about life support and
artificially supplied nutrition and
hydration, write in your initials
here: ________________
If you decide to limit your agent’s authority,
simply cross out any paragraph you
don’t like and initial it, or write any
limitation on the next page in Part 4: Do
You Have Special Instructions or Limitations
for Your Agent?
Health Care Power of Attorney Form Page 2
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