_______________________ Michigan,
___________________________________________________________________, residing at
of
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Durable Power of Attorney for Health Care
I, __________________________________ of _
(Name) (City)
hereby appoint __________________________________________________________
(Patient Advocate)
residing at
______________________________________________________________________,
(Patient Advocate Address)
as my attorney in fact (herein called patient advocate) with the following power to be exercised
in my name and for my benefit, including, but not limited to, making decisions regarding my
care, custody or medical treatment. This power of attorney has effect only if I become unable to
participate in treatment decisions.
If the first individual is unable, unwilling or unavailable to serve as my patient advocate, then I
designate
(Successor Patient Advocate)
__________________________________________________________, to serve as my
patient advocate.
(Successor Patient Address)
With respect to my personal care, my advocate shall have the power to make each and every
judgment necessary for the proper and adequate care and custody of my person, including, but
not limited to:
(If any of the following do not apply, I may cross them out and place my initials next to the item.)
A. To have access to and control over my medical and other personal information.
B. To employ and discharge physicians, nurses, therapists and any other care providers, and
to pay them reasonable compensation.
C. To give an informed consent or an informed refusal on my behalf with respect to any
medical care; diagnostic, surgical or therapeutic procedure; or other treatment of any type or
nature, including life sustaining treatments such as artificial nutrition and hydration.
D. To execute waivers, medical authorizations and such other approval as may be required to
permit or authorize care that I may need or to discontinue care that I am receiving.
E. To make decisions that could or would allow my death (except if I am pregnant).
F. My advocate shall be guided in making such decisions by what I have told my advocate
about personal preferences regarding such care. Some of those preferences may be
recorded below:
(Recording any of your preferences is optional.)
My wishes concerning care are as follows:
WP 11479 AUG !0 DurablePOAHealthcare 0810
