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Arkansas Durable Power of Attorney for Health Care Form


Arkansas Durable Power of Attorney for Health Care Form
Arkansas Durable Power of Attorney for Health Care Form
ARKANSAS DURABLE POWER OF ATTORNEY FOR HEALTH CARE
(Arkansas Statute Sec 20-13-104)
I,
, of , City of
, County of , Arkansas, hereby make,
constitute and appoint
, whose
address is
to act as my agent or attorney
in fact, to make health care and related personal decisions for me as
authorized in this document. Should
for any
reason be unable or unwilling to act, temporarily or permanently, then I
appoint
, of as such agent/attorney in fact,
with the same authority.
This Durable Power Of Attorney is made pursuant to the
Arkansas Durable Power of Attorney for Health Care Act (Ark. Code
Ann. ยง 20-13-104), and I do hereby designate and appoint
as my agent, or attorney in fact, to make
decisions regarding my health care during periods when my health care
provider has determined that I lack capacity to decide for myself.
Specifically, and not to limit any other rights prescribed under the Act,
my attorney-in-fact shall have the power to have access to my medical
records for treatment or payment decisions; to disclose medical records
to others for purposes of treatment, payment, or health care operations;
to employ and discharge physicians; to consent to or refuse to consent to
medical procedures, including the withholding or withdrawal of life-
sustaining treatment, and nutrition and hydration, according to my
wishes expressed in my Living Will, or, if my wishes are unclear under
the then existing circumstances of my medical condition, then upon
consideration of my best interests as determined by my physician in
consultation with my agent; to admit me to hospitals, including
psychiatric hospitals, nursing homes, or hospice care; and to sign all
appropriate forms, consents and releases in connection with any of said
matters. . If I should either (1) have an incurable or irreversible condition
that will cause my death within a relatively short time and I am no longer
able to make decisions regarding my medical treatment; or (2) if I should
become permanently unconscious, my health care agent and any
alternate health care agent shall also have the authority to make
decisions regarding the providing, withholding or withdrawing of life
sustaining treatment pursuant to the Arkansas Rights of the Terminally
Ill or Permanently Unconscious Act.
Arkansas Durable Power of Attorney for Health Care Form
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