Deceased Records
You have the right to give instructions about your own health care. You also have the right to name
someone else to make health care decisions for you. This form also lets you write down your wishes
regarding donation of organs and the designation of your primary physician. If you use this form, you may
complete or change all or any part of it. You are free to use a different form.
You have the right to change or revoke this advance health care directive at any time.
Part 1 — Power of Attorney for Health Care
(1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care
decisions for me:
Name of individual you choose as agent:You have the right to give instructions about your own health care. You also have the right to name
someone else to make health care decisions for you. This form also lets you write down your wishes
regarding donation of organs and the designation of your primary physician. If you use this form, you may
complete or change all or any part of it. You are free to use a different form.
You have the right to change or revoke this advance health care directive at any time.
Part 1 — Power of Attorney for Health Care
(1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care
decisions for me:
Name of individual you choose as agent:
Deceased Records
Deceased Records
Deceased Records
Deceased Records
Deceased Records
Deceased Records
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