APPOINTMENT OF HEALTH CARE REPRESENTATIVE
						and
				MEDICAL POWER OF ATTORNEY

 
 
I, ____________________________________________, hereby appoint: 
                                   (name) 
 
____________________________________________________________ 
(name of health care representative) 
 
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  
(address of health care representative) 
 
___________________________________________________________ 
 
_____________________________ (home phone number) 
 
_____________________________ (work phone number) 
     
to be my health care representative and to have medical power of attorney for me.
My representative is empowered to make any and all health care 
decisions for me, including decisions to accept or to refuse any treatment, 
service or procedure used to diagnose or treat my physical or mental 
condition, and decisions to provide, withhold or withdraw life-sustaining 
treatment. I direct my health care representative to make decisions on my 
behalf in accordance with my wishes as stated in this document, or as 
otherwise known to him or her. In the event my wishes are not clear, or if 
a situation arises that I did not anticipate, my healthcare representative is 
authorized to make decisions in my best interests. 
If the person I have designated above is unable, unwilling or unavailable 
to act as my health care representative, I hereby designate the following 
person(s) to act as my health care representative, in the following order 
of priority: 
 
1.Name______________________________________________________ 
 
Address _____________________________________________________ 
 
 
City __________________________________ State _________________ 
 
 
Telephone ___________________________________________________ 


 
2. Name ____________________________________________________ 
 
 
Address _____________________________________________________ 
 
 
City __________________________________ State _________________ 
 
 
Telephone ___________________________________________________ 
 
 
I direct that my health care representative comply with the following 
instructions and/or limitations (optional): 
 
 
 
 
 
 
 
 
 
 By writing this advance directive, I inform those who may become 
responsible for my health care of my wishes and intend to ease the 
burdens of decision making which this responsibility may impose. I have 
discussed the terms of this designation with my health care 
representative(s) and my representative(s) has/have willingly agreed to 
accept the responsibility for acting on my behalf in accordance with this 
directive and my wishes. I understand the purpose and effect of this 
document and sign it knowingly, voluntarily and after careful deliberation. 
 
Signed this _________ day of ______________________ 20 _________. 
 
Signature ___________________________________________________ 
 
Address ____________________________________________________ 
 
City _________________________________ State _________________ 
 
I declare that the person who signed this document or asked another to 
sign this document on his or her behalf, did so in my presence, that he or 
she appears to be of sound mind and free of duress or undue influence. I 
am 18 years of age or older, and am not designated by this or any other 
document as the person’s health care representative or alternate health 
care representative. 
 
1. Witness __________________________________________________ 
 
Address ____________________________________________________  
 
City __________________________________ State ________________ 
 
Signature & Date______________________________________________ 
 
2. Witness __________________________________________________ 
 
Address ____________________________________________________  
 
City _________________________________ State _________________ 
 
Signature & Date ________________________________________