HE FORM below is provided as an educational example of a limited power of attorney form. In most cases, this form will not be legal in your location. But this will give you an idea of the content of a typical form. The form you use should be obtained locally from appropriate sources.

This form is provided here as an example only and does not constitute legal advice. Consult properly authorized professionals in your community to obtain the correct form for the legal jurisdiction where you live.

                      Health Care Power of Attorney

     I, __________________________, as principal, designate 
_________________ as my agent for all matters relating to my health 
care, including, without limitation, full power to give or refuse 
consent to all medical, surgical, hospital and related health care. 
This power of attorney is effective on my inability to make or 
communicate health care decisions. All of my agent's actions under 
this power during any period when I am unable to make or communicate 
health care decisions or when there is uncertainty whether I am dead 
or alive have the same effect on my heirs, devisees and personal 
representatives as if I were alive, competent and acting for myself. 

     If my agent is unwilling or unable to serve or continue to serve, 
I hereby appoint ____________________ as my agent.

     I have _____ I have not _____ completed and attached a living 
will for purposes of providing specific direction to my agent in 
situations that may occur during any period when I am unable to 
make or communicate health care decisions or after my death. My 
agent is directed to implement those choices I have initialed in 
the living will.

     I have _____ I have not _____ completed a prehospital medical 
care directive.

     This health care directive is made under state law, and continues 
in effect for all who may rely on it except those to whom I have 
given notice of its revocation.

___________________________ 
Signature


     IN WITNESS WHEREOF, I have hereunto set my hand and seal
this _______ day of _______________________, 20____. 

Signed, sealed and delivered in the presence of: 


_____________________________      _____________________________
Witness

_____________________________
Witness

State of _____________ )
                       ) ss.
County of ____________ )

     The foregoing instrument was acknowledged by me this ______ 
day of _____________, 20 ____ by:_______________________________
who is/are personally known by me or who has/have produced:_____
______________________ as identification and who did not take an 
oath.

                         ________________________________ (SEAL)
                         Notary Public 
                         State of
My Commission Expires:

Return to list of example forms
Return to power of attorney information