1. Designation of Healthcare Agent

I, _________________________hereby appoint _______________________________,
as my attorney-in-fact ("Agent") to make health and personal care    decisions for me.
 

2. Effective Date and Durability

By this document I intend to create a durable power of attorney effective upon, and only during, any period of incapacity in which, in the opinion of my agent and attending physician, I am unable to make or communicate a healthcare decision.
 

3. Agent's Powers

I grant to my Agent full authority to make decisions for me regarding my healthcare.  I direct my Agent to follow my desires as stated in this document or otherwise known to my Agent, and to attempt to discuss proposed decisions with me to determine my desires if I am able to communicate in any way.  If my Agent cannot determine my wishes, then my Agent shall make a choice for me based upon what my Agent believes to be in my best interests.  My Agent's authority is intended to be as broad as possible.  Accordingly, unless specifically limited by Section 4, below, my Agent is authorized as follows:

(a) To consent, refuse, or withdraw consent to any and all types of medical care, treatment, medical procedures, diagnostic procedures, medication, and the use of  mechanical or other procedures that affect any bodily function, including (but not limited to) artificial respiration, nutritional support and hydration, and cardiopulmonary resuscitation;

(b) To have access to medical records and information to the same extent that I am  entitled to, including the right to disclose the contents to others;

(c) To authorize my admission to or discharge (even against medical advice) from any hospital nursing home, residential care, assisted living or similar facility or service;

(d) To contract on my behalf for any healthcare-related service or facility;

(e) To hire and fire medical, social service, and other support personnel responsible for my care;

(f) To authorize any medication or procedures intended to relieve pain, even though such use may lead to physical damage, addiction, or hasten the moment of (but not intentionally cause) my death;

(g) To make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains, to the extent permitted by law;

(h) To take any other action necessary to do what I authorize here, including (but not limited to) granting any waiver or release from liability required by any hospital physician, or other healthcare provider; signing any documents relating to refusals of treatment or the leaving of a facility against medical advice, and pursuing any legal action in my name and at the expense of my estate to force compliance with my wishes.
 

With respect to any life-sustaining treatment, I direct the following: I specifically direct my Agent to follow any healthcare declaration or Living Will executed by me.
 

5. Successors

If any Agent named by me shall die, become legally disabled, resign, refuse to act, be unavailable, or (if any Agent is my spouse) be legally separated or divorced from me, I name the following as successor to my Agent:
 
_________________________________________________
 

6.  Nomination of Guardian

If a guardian of my person should for any reason be appointed, I nominate my Agent (or his or her successor), named above.
 

7. Protection of Third Parties Who Rely on My Agent

No person who relies in good faith upon any representations by my Agent or Successor Agent shall be liable to me, my estate, my heirs or assigns, for recognizing the Agent's authority.
 

8. Execution

By signing here I indicate that I understand the contents of this document and the effect of this grant of powers to my agent.
 

I sign my name to this Durable Power of Attorney for Healthcare on this _____day of ______________, 200___.
 

Signature:__________________

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(Witnesses may not be your appointed agent; people related to you by blood, marriage, or adoption; or your healthcare provider or an employee of that provider.)

Witness #1
Signature:_________________________________
Print name:________________________________
Address:__________________________________

Witness #2
Signature:_________________________________
Print name:________________________________
Address:___________________________________