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Part V - Michigan Durable Power of Attorney Form
I ___________________, am of sound mind, and I voluntarily make this designation.
I designate______________________________, living at ___________________________________________ as my patient advocate to make care, custody and medical treatment decisions for me in the event I become unable to participate in medical treatment decisions. If my first choice cannot serve, I designate ______________________________________ living at __________________________ to serve as my successor patient advocate.
The determination of when I am unable to participate in medical treatment decisions shall be made by my attending physician and another physician or licensed psychologist.
In making decisions for me, my patient advocate shall follow my wishes of which he or she is aware, whether expressed orally, in a living will, or in this designation.
My patient advocate has authority to consent to or refuse treatment on my behalf, to arrange medical services for me, including admission to a hospital or nursing care facility, and to pay for such services with my funds. My patient advocate shall have access to any of my medical records to which I have a right.
With respect to my care, custody and medical treatment, my advocate shall have the power to make each and every judgment necessary for the proper and adequate care and custody of my person, including, but not limited to:
* access to and control over my medical and personal information.
* selection and discharge of physicians, nurses, therapists and any other care providers, and to pay them reasonable compensation with my funds.
* giving informed consent or an informed refusal on my behalf with respect to any medical care; diagnostic, surgical or therapeutic procedure; or other treatment of any type or nature.
* execution of waivers, medical authorizations and such other approval as may be required to permit or authorize care which I may need, or to discontinue care that I am receiving.
My advocate shall be guided in making such decisions by what I have told my advocate about personal preferences regarding such care. Other wishes concerning care are the following:
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
(Optional) I authorize my patient advocate to make a decision to withhold or withdraw treatment which could or would allow me to die. I acknowledge that such a decision could or would allow me to die.
____________________________________________________________________________
(Your Name and Date)
Sign this statement if you wish to give this authority to your advocate.
This Durable Power of Attorney for Healthcare shall not be affected by my disability or incapacity. This Durable Power of Attorney for Healthcare is governed by Michigan law. I may revoke this designation at any time by communicating in any manner that this designation does not reflect my wishes.
It is my intent that my family, the medical facility, and any doctors, nurses and other medical personnel involved in my care not be liable for implementing the decisions of my patient advocate or honoring wishes expressed in this designation.
Photostatic copies of this document, after it is signed and witnessed, shall have the same legal force as the original document.
I voluntarily sign this Durable Power for Attorney of Healthcare after careful consideration. I accept its meaning and I accept its consequences.
_________________________________________________
(YOUR SIGNATURE)
_________________________________________________
(YOUR STREET ADDRESS)
_________________________________________________
(CITY, MICHIGAN, ZIP CODE)
____________________
(DATE)
Notice Regarding Witnesses
You must have two adult witnesses who should be disinterested individuals and must not be your spouse, parent, child, grandchild, sibling, presumptive heir, physician, patient advocate, an employee of your life or health insurance provider, an employee of a health facility that is treating you, or an employee of a home for the aged.
Statement Of Witnesses
We sign below as witnesses. This declaration was signed in our presence. The declarant appears to be of sound mind, and to be making this designation voluntarily, and under no duress, fraud or undue influence.
Witness 1 signature: _______________________________________________
_______________________________________________________________
(PRINT OR TYPE FULL NAME)
Address: ________________________________________________________
Witness 2 signature: ________________________________________________
________________________________________________________________
(PRINT OR TYPE FULL NAME)
Address: _________________________________________________________
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