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General Medical Power of Attorney Form 2

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General Medical Power of Attorney Form 2 Page 2
document to make, my agent has the power and authority to
execute on my behalf all of the following:
1. Documents titled or purporting to be a "Refusal to
Permit Treatment" and "Leaving Hospital Against
Medical Advice";
2. Any necessary waiver or release from liability required
by a hospital or physician.
Duration: This power of attorney exists indefinitely from its
date of execution, unless I establish herein a shorter time or
revoke the power of attorney.
[If applicable: This power of attorney expires on [DATE]. If I
am unable to make health care decisions for myself when
this power of attorney expires, the authority I have granted
my agent shall continue to exist until such time as I become
able to make health care decisions for myself.]
Alternative Agent: In the event that my designated agent
becomes unable, unwilling, or ineligible to serve, I hereby
designate [NAME], presently residing at [ADDRESS],
telephone number [PHONE NUMBER] as my as my first
alternate agent, and [NAME], presently residing at
[ADDRESS], telephone number [PHONE NUMBER] as my
as my second alternate agent.
Prior Designations Revoked: I revoke any prior Medical
Power of Attorney.
Location of Documents:
The original copy of this Medical Power of Attorney is located
at [Location].
Signed copies of this Medical Power of Attorney have been
General Medical Power of Attorney Form 2