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Minnesota Health Care Power of Attorney Form


Minnesota Health Care Power of Attorney Form
Minnesota Health Care Power of Attorney Form
HEALTH CARE DIRECTIVE
I, ,
understand this document allows me to do ONE OR BOTH of the following:
PART I: Name another person (called the health care agent) to make health care decisions for
me if I am unable to decide or speak for myself. My health care agent must make health
care decisions for me based on the instructions I provide in this document (Part II), if
any, the wishes I have made known to him or her, or must act in my best interest if I
have not made my health care wishes known.
AND/OR
P
ART II: Give health care instructions to guide others making health care decisions for me. If I
have named a health care agent, these instructions are to be used by the agent. These
instructions may also be used by my health care providers, others assisting with my
health care and my family, in the event I cannot make decisions for myself.
P
ART I: APPOINTMENT OF HEALTH CARE AGENT
THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS
FOR ME IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF
(I know I can change my agent or alternate agent at any time and
I know I do not have to appoint an agent or an alternate agent.)
NOTE: If you appoint an agent, you should discuss this health care directive with your agent and
give your agent a copy. If you do not wish to appoint an agent, you may leave Part I
blank and go to Part II.
When I am unable to decide or speak for myself, I trust and appoint
to make health care decisions for me. This person is called my health care agent.
Relationship of my health care agent to me:
Telephone number of my health care agent:
Address of my health care agent:
APPOINTMENT OF ALTERNATE HEALTH CARE AGENT (OPTIONAL): If my health care agent is not
reasonably available, I trust and appoint
to make health care decisions for me. This person is called my health care agent.
Minnesota Health Care Power of Attorney Form
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