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MEDICAL DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS
I. APPOINTMENT OF AGENT AND
ALTERNATES
I, ____________________________________ ,
Declarant, hereby appoint:
Name of Agent
Agent’s Best Contact Telephone Number
Agent’s email or alternative telephone number
Agent’s home address
as my Agent to make and communicate my healthcare
decisions when I cannot. This gives my Agent the
power to consent to, or refuse, or stop any healthcare,
treatment, service, or diagnostic procedure. My Agent
also has the authority to talk with healthcare personnel,
get information, and sign forms as necessary to carry out
those decisions.
If the person named above is not available or is unable
to continue as my Agent, then I appoint the following
person(s) to serve in the order listed below.
Name of Alternate Agent #1
Agent’s Best Contact Telephone Number
Agent’s email or alternative telephone number
Agent’s home address
Name of Alternate Agent #2
Agent’s Best Contact Telephone Number
Agent’s email or alternative telephone number
Agent’s home address
II. WHEN AGENT’S POWERS BEGIN
By this document, I intend to create a Medical Durable
Power of Attorney which shall take effect either
(initial
one)
:
______ (Initials) Immediately upon my signature.
______ (Initials) When my physician or other qualified
medical professional has determined that I am unable to
make my or express my own decisions, and for as long
as I am unable to make or express my own decisions.
III. INSTRUCTIONS TO AGENT
My Agent shall make healthcare decisions as I direct
below, or as I make known to him or her in some other
way. If I have not expressed a choice about the decision
or healthcare in question, my Agent shall base his or her
decisions on what he or she, in consultation with my
healthcare providers, determines is in my best interest. I
also request that my Agent, to the extent possible,
consult me on the decisions and make every effort to
enable my understanding and find out my preferences.
State here any desires concerning life-sustaining
procedures, treatment, general care and services,
including any special provisions or limitations:
My signature below indicates that I understand the
purpose and effect of this document:
Signature of Declarant Date
Pursuant to Colorado Revised Statute 15-14.503–509
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