My primary healthcare agent
I appoint:
Agent's name
Address
Home phone
Work phone
My rst alternate healthcare agent
Agent's name
Address
Home phone
Work phone
My second alternate healthcare agent
Agent's name
Address
Home phone
Work phone
Reasons for naming healthcare provider (if applicable)
I have named as my agent a healthcare provider, or employee of a healthcare provider, who is currently or might be providing direct
care to me when decisions are needed. That person is not related to me by blood, marriage, registered domestic partnership, or
adoption. My reasons for wanting to appoint that person as my agent are:
Powers of my agent
If I am unable to decide or speak for myself, my agent has the power to:
• Consent to, refuse, or withdraw any health care, treatment, service, or procedure.
• Stop or not start health care that is keeping or might keep me alive.
• Choose my healthcare providers.
• Choose where I live when I need health care and what personal security measures are needed to keep me safe.
• Obtain copies of my medical records and allow others to see them.
4 Highway 75 North and 210 West
