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

authority.

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

decisions.

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

name.

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?

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