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Colorado Health Care Power of Attorney Form

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The Colorado 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.

Colorado Health Care Power of Attorney Form Page 2
Colorado Health Care Power of Attorney Form
ADDENDUM TO MEDICAL DURABLE POWER OF ATTORNEYRECOMMENDED, NOT REQUIRED
1. Signature of the Appointed Agent
Although not required by Colorado law, my signature
below indicates that I have been informed of my
appointment as a Healthcare Agent under Medical
Durable Power of Attorney for (name of Declarant)
.
I accept the responsibilities of that appointment, and I
have discussed with the Declarant his or her wishes and
preferences for medical care in the event that he or she
cannot speak for him- or herself.
I understand that I am always to act in accordance with
his or her wishes, not my own, and that I have full
authority to speak with his or her healthcare providers,
examine healthcare records, and sign documents in order
to carry out those wishes. I also understand that my
authority as a Healthcare Agent is only in effect when
the Declarant is unable to make his or her own decisions
and that it automatically expires at his or her death.
If I am an alternate Agent, I understand that my
responsibilities and powers will only take effect if the
primary Agent is unable or unwilling to serve.
Primary Agent’s Signature
Printed Name
Date
Alternate Agent #1 Signature
Printed Name
Date
Alternate Agent #2 Signature
Printed Name
Date
2. Signature of Witnesses and Notary
The signature of two witnesses and a notary seal are not
required by Colorado law for proper execution of a
Medical Durable Power of Attorney; however, they may
make the document more acceptable in other states.
This document was signed by (name of Declarant)
in our presence, and we, in the presence of each other,
and at the Declarant’s request, have signed our names
below as witnesses. We declare that, at the time the
Declarant signed this document, we believe that he or
she was of sound mind and under no pressure or undue
influence. We are at least eighteen (18) years old.
Signature of Witness
Printed Name
Address
Signature of Witness
Printed Name
Address
Notary Seal (optional)
State of ___________________________
County of }
SUBSCRIBED and sworn to before me by
, the Declarant,
and
and
witnesses, as the voluntary act and deed of the Declarant
this day of , 20 .
Notary Public
My commission expires:
Pursuant to Colorado Revised Statute 15-14.503–509
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Colorado Health Care Power of Attorney Form
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