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Sample Power of Attorney for Health Care

1.    Power of Attorney for Health Care Decisions:    This document allows another person to make health care decisions for you.  When you are unable to communicate your desire concerning health, either through age or some other disability, the nominated person can consent to various medical procedures.  In our sample family, Tom is getting up in age and is in poor health.  Tom may wish to appoint his wife or daughter, if she is of age, as Power of Attorney for Health Care Decisions.  This person can then consent to various operations should anything happen to Tom.  The Power of Attorney must be of legal age.



I (the "Principal") hereby designate Gene Sample, my spouse, as my attorney in fact (my agent) and give to my agent the power to make health care decisions for me.  This power exists only when certified that I am unable, in the judgment of my attending physician, to make those health care decisions.  The attorney in fact must act consistently with my desires as stated in this document or otherwise made known. If the person designated above is unwilling or unable to serve, I nominate Sarah Sample to serve.

In our sample, tom has appointed his wife as the person to make health care decisions for him.  If she is unable for some reason, his daughter can make them.


            Except as otherwise specified in this document, this document gives my agent the power, where otherwise consistent with the laws of the State of Anystate, to consent to my physician in not giving health care or stopping health care which is necessary to keep me alive. 

It is important to realize, that this power does include the power to withdraw health care.

            This document gives my agent power to make health care decisions on my behalf, including to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.  This power is subject to any statement of my desires and any limitations included in this document.  My agent has the right to examine my medical records and to consent to disclosure of such records.


As long as you are able, your expressed wishes will be followed, despite the language in the paragraphs above.


            This power of attorney shall not be affected by subsequent disability or incapacity of the principal.  Notwithstanding any provision herein contrary, my agent shall take no action under this instrument unless I am deemed to be disabled or incapacitated as defined herein.  My incapacity shall be deemed to exist when so certified in writing by two licensed physicians not related to either me or my agent.  The said certificate shall state that I am unable, physically or mentally, in the judgment of said physician, to make those health care decisions for myself.

The whole point of this document is to be affective while you are incapacitated.


            Notwithstanding any provision to the contrary, I retain the right to make medical and other health care decisions for myself so long as I am able to give informed consent with respect to a particular decision.  In addition, no treatment may be given to me over my objection, and health care necessary to keep me alive may not be stopped if I object.

Its worth repeating, as long as you are able, you are in control of your health care decisions.


            If I have executed a document concerning the use of life sustaining procedures, commonly referred to as a “Living Will”, the agent and his power shall be construed to compliment and not contradict said living will


            I hereby authorize all physicians and psychiatrist who have treated, or will treat me, and all other providers of health care, including hospitals, to release to my agent all information contained in my medical records which my agent may request whether oral or written. 

Since health care records are confidential, you must waive this confidentiality to so the agent can have access to your records.


Signed this _____ day of _____________________, 2002




                        Tom Sample, Principal

                        1500 Grand Avenue

                        Ourtown,  Anystate     95959


By signing this form I declare that I signed this form in the presence of the other witness and the Principal and I witnessed the signing by the Principal or other person acting on behalf of and at the Principal's direction.

Witness’s signature and addresses:

















State of Anystate,


County of Big County


            On this ____ day of ______________, A.D., 2002, before me, the undersigned, a Notary Public in and for the State of Iowa, personally appeared Tom Sample to me known to be the identical person named in and who executed the foregoing instrument, and acknowledged that he or she executed the same as his or her voluntary act and deed.




                        Notary Public in and for said State.




                1.  Place original in a safe place known and accessible to family members or close friends.

                2.  Provide a true copy to your doctor.

                3.  Provide a copy(s) to family member(s).

                4.  Provide a copy to designated attorney in fact (agent) and  to alternate designated attorney(s) in fact (if any).





It’s not our intent to give you legal advice. If you have any questions concerning the effect of any of these documents we remind you that you should contact an attorney in your state competent to advise you in this area of the law.


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