DURABLE POWER OF ATTORNEY

FOR HEALTH CARE DECISIONS

       1.  DESIGNATION OF HEALTH CARE AGENT.

       I, [NAME] (insert your name), do hereby designate and appoint:

Name: [NAME]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Telephone Number: [PHONE NUMBER]

as my agent to make health care decisions for me as authorized in this document.

       2.  CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE.

       By this document I intend to create a durable power of attorney by appointing the person designated above to make health care decisions for me. This power of attorney shall not be affected by my subsequent incapacity.

       3.  GENERAL STATEMENT OF AUTHORITY GRANTED.

       In the event that I am incapable of giving informed consent with respect to health care decisions, I hereby grant to the agent named above full power and authority: to make health care decisions for me before or after my death, including consent, refusal of consent or withdrawal of consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition; to request, review and receive any information, verbal or written, regarding my physical or mental health, including, without limitation, medical and hospital records; to execute on my behalf any releases or other documents that may be required to obtain medical care and/or medical and hospital records, EXCEPT any power to enter into any arbitration agreements or execute any arbitration clauses in connection with admission to any health care facility including any skilled nursing facility; and subject only to the limitations and special provisions, if any, set forth in paragraph 4 or 6.

       4.  SPECIAL PROVISIONS AND LIMITATIONS.

    In exercising the authority under this durable power of attorney for health care, the authority of my agent is subject to the following special provisions and limitations:

[SPECIAL PROVISIONS AND LIMITATIONS]

       5.  DURATION.

       I understand that this power of attorney will exist indefinitely from the date I execute this document unless I establish a shorter time. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent will continue to exist until the time when I become able to make health care decisions for myself.

I wish to have this power of attorney end on the following date: [DAY] day of [MONTH], 20[XX]

       6.  STATEMENT OF DESIRES CONCERNING TREATMENT.

       If the statement reflects your desires, initial the box next to the statement.

A. I desire that my life be prolonged to the greatest extent possible, without regard to my condition, the chances I have for recovery or long-term survival, or the cost of the procedures. [INITIALS]

B. If I am in a coma which my doctors or advanced practice registered nurses have reasonably concluded is irreversible, I desire that life-sustaining or prolonging treatments not be used. [INITIALS]

C. If I have an incurable or terminal condition or illness and no reasonable hope of long-term recovery or survival, I desire that life-sustaining or prolonging treatments not be used. [INITIALS]

D. Withholding or withdrawal of artificial nutrition and hydration may result in death by starvation or dehydration. I want to receive or continue receiving artificial nutrition and hydration by way of the gastrointestinal tract after all other treatment is withheld. [INITIALS]

E. I do not desire treatment to be provided and/or continued if the burdens of the treatment outweigh the expected benefits. My agent is to consider the relief of suffering, the preservation or restoration of functioning, and the quality as well as the extent of the possible extension of my life. [INITIALS]

F. If I have an incurable or terminal condition, including late stage dementia, or illness and no reasonable hope of long-term recovery or survival, I desire my attending physician to administer any medication to alleviate suffering without regard that the medication is likely to cause addiction or reduce the extension of my life. [INITIALS]

       7.  STATEMENT OF DESIRES CONCERNING LIVING ARRANGEMENTS

A. I desire to live in my home as long as it is safe and my medical needs can be met. My agent may arrange for a natural person, employee of an agency or provider of community-based services to come into my home to provide care for me. When it is no longer safe for me to live in my home, I authorize my agent to place me in a facility or home that can provide any medical assistance and support in my daily activities. Before being placed in such a facility or home, I wish for my agent to discuss and share information concerning the placement with me. [INITIALS]

B. I desire to live in my home for as long as possible without regard for my medical needs, personal safety or ability to engage in activities of daily living. My agent may arrange for a natural person, an employee of an agency or a provider of community-based services to come into my home and provide care for me. I understand that, before I may be placed in a facility or home other than the home in which I currently reside, a guardian must be appointed for me. [INITIALS]

       8.  DESIGNATION OF ALTERNATE AGENT.

       If the person designated in paragraph 1 as my agent is unable to make health care decisions for me, then I designate the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below:

Alternative Agent
Name: [NAME]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
Telephone Number: [PHONE NUMBER]

       9.  PRIOR DESIGNATIONS REVOKED.

       I revoke any prior durable power of attorney for health care.

             13.  RELEASE OF INFORMATION.

       I agree to, authorize and allow full release of information by any government agency, medical provider, business, creditor or third party who may have information pertaining to my health care, to my agent named herein, pursuant to the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as amended, and applicable regulations.

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)

      I sign my name to this Durable Power of Attorney for Health Care on [DAY] day of [MONTH], 20[XX] (date) at [CITY] (city), [STATE] (state).

________________________________________________

                                                                                                      (Signature)

       THIS POWER OF ATTORNEY WILL NOT BE VALID FOR MAKING HEALTH CARE DECISIONS UNLESS IT IS EITHER (1) SIGNED BY AT LEAST TWO QUALIFIED WITNESSES WHO ARE PERSONALLY KNOWN TO YOU AND WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC.

STATEMENT OF WITNESSES

       I declare under penalty of perjury that the principal is personally known to me, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as agent by this document and that I am not a provider of health care, an employee of a provider of health care, the operator of a health care facility or an employee of an operator of a health care facility.

Signature: ____________________________________
Print Name: __________________________________
Residence Address: [ADDRESS, CITY, STATE, ZIP CODE]
Date: [DAY] day of [MONTH], 20[XX]

Signature: ___________________________________
Print Name: __________________________________
Residence Address: [ADDRESS, CITY, STATE, ZIP CODE]
Date: [DAY] day of [MONTH], 20[XX]

       (AT LEAST ONE OF THE ABOVE WITNESSES MUST ALSO SIGN THE FOLLOWING DECLARATION.)

       I declare under penalty of perjury that I am not related to the principal by blood, marriage or adoption and that to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.

Signature: ___________________________________
Print Name: __________________________________
Residence Address: [ADDRESS, CITY, STATE, ZIP CODE]
Date: [DAY] day of [MONTH], 20[XX]