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Ohio Health Care Power of Attorney Form 1

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The Ohio health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.

Ohio Health Care Power of Attorney Form 1 Page 2
(h) To execute on my behalf any or all of the following:
(1) Documents that are written consents to medical treatment, Do Not Resuscitate orders, or
other similar orders;
(2) Documents that are written requests that I be transferred to another facility, written
requests to be discharged against medical advice, or other similar requests; and
(3) Any other document necessary or desirable to implement health care decisions that my
agent is authorized to make pursuant to this document.
4. WITHDRAWAL OF NUTRITION AND HYDRATION WHEN IN A PERMANENTLY
UNCONSCIOUS STATE.
If I have marked the foregoing box and have placed my initials on the line adjacent to it, my agent may
refuse, or in the event treatment has already commenced, withdraw informed consent to the provision of
artificially or technologically supplied nutrition and hydration if I am in a permanently unconscious state and if
my attending physician and at least one other physician who has examined me determine, to a reasonable degree
of medical certainty and in accordance with reasonable medical standards, that such nutrition or hydration will
not or no longer will serve to provide comfort to me or alleviate my pain.
5. DESIGNATION OF ALTERNATE AGENT. Because I wish that an agent shall be available
to exercise the authorities granted hereunder at all times, I further designate each of the following individuals to
succeed to such authorities and to serve under this instrument, in the order names, if at any time the agent first
names (or any alternate designee) is not readily available or is unwilling or unable to serve or to continue to
serve:
First Alternated Agent_____________________________________________________
(Name) (Relationship)
presently residing at _________________________________Phone:_______________________
Second Alternated Agent __________________________________________________
(Name) (Relationship)
presently residing at _________________________________Phone:_______________________
Each alternated shall have and exercise all of the authority conferred above.
6. NO EXPIRATION DATE. This Durable Power of Attorney for Health Care shall not be
affected by my disability or by lapse of time. This Durable Power of Attorney for Health Care
shall have no expiration date.
7. SEVERABILITY. Any invalid or unenforceable power, authority or provision of this
instrument shall not affect any other power, authority or provision or the appointment of my
agent to make health care decisions.
8. PRIOR DESIGNATIONS REVOKED. I hereby revoke any prior Durable Power of Attorney
for Health Care executed by me under Chapter 1337 of the Ohio Revised Code.
Ohio Health Care Power of Attorney Form 1