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Ohio Health Care Power of Attorney Form 1

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
Ohio Health Care Power of Attorney Form 1
1. DESIGNATION OF ATTORNEY-IN-FACT.
I, _______________________________________, presently residing at _________________
___________________________, Ohio, (the”Principal”) being of sound mind and not under or subject to
duress, fraud or undue influence, intending to create a Durable Power of Attorney for Health Care under
Chapter 1337 of the Ohio Revised Code, as amended from time to time, do hereby designate and appoint:
_________________________________________________________ _______________________
(Name)
(Relationship)
presently residing at ________________________________________ Phone________________
as my attorney-in-fact who shall act as my agent to make health care decisions for me as authorized in this
document.
2. GENERAL STATEMENT OF AUTHORITY GRANTED. I hereby grant to my agent full
power and authority to make all health care decisions for me to the same extent that I could make such decisions
for myself if I had the capacity to do so, at any time during which I do not have the capacity to make informed
health care decisions for myself. Such agent shall have the authority to give, to withdraw or to refuse to give
informed consent to any medical or nursing procedure, treatment, intervention or other measure used to
maintain, diagnose or treat my physical or mental condition. In exercising this authority, my agent shall make
health care decisions that are consistent with my desires as stated in this document or otherwise made known to
my agent by me or, if I have not made my desires known, that are, in the judgment of my agent, in my best
interests.
3. ADDITIONAL AUTHORITIES OF AGENT. Where necessary or desirable to implement the
health care decisions that my agent is authorized to make pursuant to this document, my agent has the power
and authority to do any and all of the following:
(a) If I am in a terminal condition, to give, to withdraw or to refuse to give informed consent to life-
sustaining treatment, including the provision of artificially or technologically supplied nutrition or hydration,
(b) If I am in a permanently unconscious state, to gave, to withdraw or to refuse to give informed
consent to life-sustaining treatment ; provided, however, my agent is not authorized to refuse or direct the
withdrawal of artificially or technologically supplied nutrition or hydration unless I have specifically authorized
such refusal or withdrawal in Paragraph 4;
(c) To request, review, and receive any information, verbal or written, regarding my physical or mental
health, including, but not limited to, all of my medical and health care facility records;
(d) To execute on my behalf any releases or other documents that may be required in order to obtain this
information;
(e) To consent to the further disclosure of this information if necessary;
(f) To select, employ, and discharge health care personnel, such as physicians, nurses, therapists and
other medical professionals, including individuals and services providing home health care, as my agent shall
determine to appropriate;
(g) To select and contract with any medical or health care facility on my behalf, including, but not
limited to, hospitals, nursing homes, assisted residence facilities, and the like; and
State of Ohio
Durable Power of Attorney
for Health Care
Provided by
Danny N. Crank
Butler County Recorder
Ohio Health Care Power of Attorney Form 1
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