I, __________, appoint __________ (phone __________) as my healthcare agent. If my agent is unavailable, I appoint __________.

1. Authority

If I am unable to make or communicate my own healthcare decisions, my agent may consent to, refuse or withdraw any medical treatment, choose providers and facilities, and access my medical records under HIPAA.

2. Guidance

My agent shall act according to my known wishes and, where unknown, in my best interest.

Witness Attestation

We, the undersigned witnesses, each being at least eighteen (18) years of age, declare that __________ signed this document in our presence, appeared to be of sound mind and under no duress, and that we signed as witnesses in the presence of __________ and of each other. Neither of us is a beneficiary under this document.

Witness 1 Name and Address: ____________________________________________

Witness 2 Name and Address: ____________________________________________