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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 3
Ohio Health Care Power of Attorney Form 1
I understand the purpose and effect of this document and sign my name to this Durable Power of Attorney for
Health Care after careful deliberation on ______________ at _________________, Ohio.
(Date) (City)
___________________________________
Principal
THIS DURABLE POWER OF ATTORNEY FOR HEALTHCARE WILL NOT BE VALID UNLESS IT IS
EITHER(1) SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE PRESENT
WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A
NOTARY PUBLIC.
I attest that the principal signed or acknowledged this Durable Power of Attorney for Health Care in my
presence, and that the principal appears to be of sound mind and not under or subject to duress, fraud or undue
influence. I further attest that I am not the agent designated in this document, I am not the attending physician of
the principal, I am not the administrator of a nursing home in which the principal is receiving care, and that I am
an adult not related to the principal by blood, marriage or adoption.
Signature:______________________________ Residence Address: ______________________
Print Name: ____________________________ _________________________________
Date:__________________________________ _________________________________
Signature:______________________________ Residence Address: ______________________
Print Name: ____________________________ _________________________________
Date:__________________________________ _________________________________
OR
ACKNOWLEDGMENT
State of Ohio
County of _______________ss:
On this the ________day of ____________________, 20___, before me, the undersigned Notary Public,
personally appeared __________________________________________, known to me or satisfactorily proven
to be the person whose name is subscribed to the above Durable Power of Attorney for Health Care as the
principal, and acknowledged that (s)he executed the same for the purposes expressed therein. I attest that the
principal appears to be of sound mind and not under or subject to duress, fraud or undue influence.
My Commission
Expires: _____________________ ___________________________________
Notary Public
NOTE: YOU MAY WISH TO GIVE EXECUTED COPIES OF THIS DURABLE POWER OF ATTORNEY FOR HEALTH CARE TO THE AGENT NAMES IN
THIS DOCUMENT, EACH ALTERNATE AGENT , AND TO YOUR LAWYER, YOUR PERSONAL PHYSICIAN AND MEMBERS OF YOUR FAMILY.
Ohio Health Care Power of Attorney Form 1