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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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PROVISION OF FEEDING TUBE
If I have checked “Yes” to the following, my health care agent may have a feeding tube withheld or
withdrawn from me, unless my physician has advised that, in his or her professional judgment, this will cause me
pain or will reduce my comfort. If I have checked “No” to the following, my health care agent may not have a
feeding tube withheld or withdrawn from me.
My health care agent may not have orally ingested nutrition or hydration withheld or withdrawn from me
unless provision of the nutrition or hydration is medically contraindicated.
Withhold or withdraw a feeding tube - - Yes No
If I have not checked either “Yes” or “No” immediately above, my health care agent may not have a feeding
tube withdrawn from me.
HEALTH CARE DECISIONS FOR PREGNANT WOMEN
If I have checked “Yes” to the following, my health care agent may make health care decisions for me even if
my agent knows I am pregnant. If I have checked “No” to the following, my health care agent may not make
health care decisions for me if my health care agent knows I am pregnant.
Health care decision if I am pregnant - - Yes No
If I have not checked either “Yes” or “No” immediately above, my health care agent may not make health care
decisions for me if my health care agent knows I am pregnant.
STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS
In exercising authority under this document, my health care agent shall act consistently with my following
stated desires, if any, and is subject to any special provisions or limitations that I specify. The following are any
specific desires, provisions or limitations that I wish to state (add more items if needed):
1.
2.
3.
INSPECTION AND DISCLOSURE OF INFORMATION
RELATING TO MY PHYSICAL OR MENTAL HEALTH
Subject to any limitations in this document, my health care agent has the authority to do all of the following:
(a) Request, review, and receive any information, oral or written, regarding my physical or mental health,
including medical and hospital records.
(b) Execute on my behalf any documents that may be required in order to obtain this information.
(c) Consent to the disclosure of this information.
F-00085 (Rev. 06/11)
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