Health Directive Power of Attorney Form

Please complete this form to designate an individual to make healthcare decisions.

Principal Information

Name

    Date of Birth

      Address

        Phone Number

          Agent Information

          Name

            Relationship to Principal

              Address

                Phone Number

                  Scope of Authority

                  I hereby appoint the above agent to make healthcare decisions on my behalf, including but not limited to:

                    • Consenting to or refusing medical treatments

                    • Admitting or discharging me from healthcare facilities

                    • Accessing my medical records

                    • Communicating with healthcare providers about my care

                    • Making decisions about end-of-life care consistent with my wishes

                    Limitations or Special Instructions

                      Signatures

                      By signing below, I declare that I understand the purpose of this document and that I am authorizing the named individual to make healthcare decisions on my behalf. I affirm that this document reflects my wishes.

                      Principal

                      Name:

                      Date:

                      Witness

                      Name:

                      Date:

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