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Medical Power of Attorney
Effective Upon Execution
I, [NAME], a resident of [ADDRESS. COUNTY, STATE];
Social Security Number [NUMBER] designate [NAME],
presently residing at [ADDRESS], telephone number
[PHONE NUMBER] as my agent to make any and all health
care decisions for me, except to the extent I state otherwise
in this document. For the purposes of this document, "health
care decision" means consent, refusal of consent, or
withdrawal of consent to any care, treatment, service, or
procedure to maintain, diagnose, or treat an individual's
physical or mental condition. This medical power of attorney
takes effect if I become unable to make my own health care
decisions and this fact is certified in writing by my physician.
Limitations: [Describe any desired limitations, for example,
concerning life support, life-prolonging care, treatment,
services, and procedures.]
Inspection and Disclosure of Information Relating to My
Physical or Mental Health: Subject to any limitations in this
document, my agent has the power and authority to do all of
1. Request, review, and receive any information, verbal or
written, regarding my physical or mental health,
including, but not limited to, medical and hospital
2. Execute on my behalf any releases or other documents
that may be required in order to obtain this information;
3. Consent to the disclosure of this information.
Additional Powers: Where necessary to implement the
health care decisions that my agent is authorized by this
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