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Health Care Power of Attorney Template


Health Care Power of Attorney Template Page 2
Health Care Power of Attorney Template
HEALTH CARE POWER OF ATTORNEY
DESIGNATION OF PATIENT ADVOCATE
TO MY FAMILY, DOCTORS AND ALL CONCERNED WITH MY CARE:
These instructions express my wishes about my health care. I want my family, doctors, and
everyone else concerned with my care to act in accord with them.
1. Appointment of Patient Advocate
I appoint the following person my Patient Advocate:
Patient Advocate’s Name:
Address:
2. Appointment of Successor Patient Advocate
I appoint the following person my successor Patient Advocate if my Patient Advocate
does not accept my appointment, is incapacitated, resigns or is removed. My successor Patient
Advocate is to have the same powers and rights as my Patient Advocate.
Name:
[Successor]
Address:
My Patient Advocate may delegate her powers to the successor Patient Advocate if she is
unable to act.
My Patient Advocate or successor Patient Advocate may only act if I am unable to
participate in making decisions regarding my medical treatment.
3. Instructions for Care
My Patient Advocate shall have the authority to make all decisions and to take all actions
regarding my care, custody and medical treatment, including, but not limited to the following:
Health Care Power of Attorney Template