I understand that this power of attorney exists indefinitely from the date I execute this document
unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care
decisions for myself when this power of attorney expires, the authority I have granted my agent
continues to exist until the time I become able to make health care decisions for myself.
I revoke any prior medical power of attorney.
THIS MEDICAL POWER OF ATTORNEY IS AN IMPORTANT LEGAL DOCUMENT. BEFORE
SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
Except to the extent you state otherwise, this document gives the person you name as your
agent the authority to make any and all health care decisions for you in accordance with your
wishes, including your religious and moral beliefs, when you are unable to make the decisions
for yourself. Because "health care" means any treatment, service, or procedure to maintain,
diagnose, or treat your physical or mental condition, your agent has the power to make a broad
range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw
consent to medical treatment and may make decisions about withdrawing or withholding life-
sustaining treatment. Your agent may not consent to voluntary inpatient mental health services,
convulsive treatment, psychosurgery, or abortion. A physician must comply with your agent's
instructions or allow you to be transferred to another physician.
Your agent's authority is effective when your doctor certifies that you lack the competence to
make health care decisions.
Your agent is obligated to follow your instructions when making decisions on your behalf.
Unless you state otherwise, your agent has the same authority to make decisions about your
health care as you would have if you were able to make health care decisions for yourself.
It is important that you discuss this document with your physician or other health care provider
before you sign the document to ensure that you understand the nature and range of decisions
that may be made on your behalf. If you do not have a physician, you should talk with someone
else who is knowledgeable about these issues and can answer your questions. You do not
need a lawyer's assistance to complete this document, but if there is anything in this document
that you do not understand, you should ask a lawyer to explain it to you.
The person you appoint as agent should be someone you know and trust. The person must be
18 years of age or older or a person under 18 years of age who has had the disabilities of
minority removed. If you appoint your health or residential care provider (e.g., your physician or
an employee of a home health agency, hospital, nursing facility, or residential care facility, other
than a relative), that person has to choose between acting as your agent or as your health or
residential care provider; the law does not allow a person to serve as both at the same time.
You should inform the person you appoint that you want the person to be your health care agent.
You should discuss this document with your agent and your physician and give each a signed
copy. You should indicate on the document itself the people and institutions that you intend to
have signed copies. Your agent is not liable for health care decisions made in good faith on
Once you have signed this document, you have the right to make health care decisions for
yourself as long as you are able to make those decisions, and treatment cannot be given to you
or stopped over your objection. You have the right to revoke the authority granted to your agent
by informing your agent or your health or residential care provider orally or in writing or by your
execution of a subsequent medical power of attorney. Unless you state otherwise in this
document, your appointment of a spouse is revoked if your marriage is dissolved, annulled, or