Durable Power of Attorney for Health Care Form

June 29, 2010 | By | Reply More

A durable power of attorney for health care form is used when you need to appoint an agent to make health care decisions for you in the event that you are incapacitated.  This form allows the consent to last for a longer time period but you can specify the exact length the consent lasts for.  Below is a sample durable power of attorney for health care form.

Sample Durable Power of Attorney for Health Care Form


I _______________________ being of sound mind do hereby give my consent and permission to ______________________ to make health care decisions on my behalf for a durable time period starting from _______________________ to ________________ in the event that I am incapacitated and therefore unable to make the decisions myself.  I hereby state that I am fully aware and informed about the legal obligations of the form and therefore willingly and without any coercion give my consent and authority to _________________ to make healthcare decisions for me.

Signature: ____________________________ Date: _________________________

In witness of: __________________________ Signature: _____________________

On this day of: _________________________

Category: Power of Attorney forms

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