Home > Legal > Legal > Power of Attorney Template > Vermont Power of Attorney Form > Vermont Health Care Power of Attorney Template

Vermont Health Care Power of Attorney Form

At Speedy Template, You can download Vermont Health Care Power of Attorney Form . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.
The Vermont 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.

Vermont Health Care Power of Attorney Form Page 2
Durable Power of Attorney for Health Care - Vermont
Page 2
I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this
document. I have read, or had read to me, and understand the information contained in the disclosure
statement. The original of this document will be held by my agent, and photocopies of the original will be
given to my alternate agent and the following:
_____________________________ _____________________________
_____________________________ _____________________________
_____________________________ _____________________________
In witness whereof, I have hereunto signed my name this date of ……………………, 20….
Signature ………………………………………………. Date of Birth …………………………
Address ……………………………………………………………………………………………
I declare that the principal appears to be of sound mind and free from duress at the time the durable
power of attorney for health care is signed and that the principal has affirmed that he or she is aware of
the nature of the document and is signing it freely and voluntarily.
Witness: …………………………………….. Address: ……………………………………….
Witness: …………………………………….. Address: ……………………………………….
The following is required only if this document is being signed while the principal is in or being admitted to
a hospital, nursing home or residential care home.
Statement of ombudsman, hospital representative, recognized member of the Vermont clergy, Vermont-
licensed attorney or other person designated by the county Probate Court: I declare that I have personally
explained the nature and effect of this durable power of attorney to the principal and that the principal
understands the same.
Date: ……………….
Name: ………………………………………….. Address: …………………………………….
Vermont Health Care Power of Attorney Form
Previous

2/2

Next