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A Health Care Power of Attorney is a kind of document that teaches people what needs to be prepared and how to make the power of attorney for health care. It entrusts the agent to make health care decisions for you when you are unable to do so. If you name a health care agent, you need to make sure that the agent you trust can make health care decisions for you when you become ill or injured. To correctly use the form, you need to do these three things. Firstly you need to think carefully who can be chosen to be your health care agent. Then you need to think about what guidance you want to give your health care agent in making treatment decisions. Then talk about your decisions. Finally, fill in the form and follow the instructions for signing in the presence of two witnesses.

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POWER OF ATTORNEY FOR HEALTH CARE
Document made this day of (month), (year).
CREATION OF POWER OF ATTORNEY FOR HEALTH CARE
I,
(print name, address, and date of birth), being of sound mind, intend by this document to create a power of
attorney for health care. My executing this power of attorney for health care is voluntary. Despite the creation of
this power of attorney for health care, I expect to be fully informed about and allowed to participate in any health
care decision for me, to the extent that I am able. For the purposes of this document, “health care decision” means
an informed decision to accept, maintain, discontinue, or refuse any care, treatment, service, or procedure to
maintain, diagnose, or treat my physical or mental condition.
In addition, I may, by this document, specify my wishes with respect to making an anatomical gift upon my
death.
DESIGNATION OF HEALTH CARE AGENT
If I am no longer able to make health care decisions for myself, due to my incapacity, I
hereby designate
print name, address and telephone number) to be my health care agent for the purpose of making health care
decisions on my behalf. If he or she is ever unable or unwilling to do so, I
hereby designate
(print name, address and telephone number) to be my alternate health care agent for the purpose of making health
care decisions on my behalf. Neither my health care agent nor my alternate health care agent whom I have
designated is my health care provider, an employee of my health care provider, an employee of a health care
facility in which I am a patient or a spouse of any of those persons, unless he or she is also my relative. For
purposes of this document, “incapacity” exists if 2 physicians or a physician and a psychologist who have
personally examined me sign a statement that specifically expresses their opinion that I have a condition that
means that I am unable to receive and evaluate information effectively or to communicate decisions to such an
extent that I lack the capacity to manage my health care decisions. A copy of that statement must be attached to
this document.
F-00085 (Rev. 06/11)
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