MAKE YOUR FREE Oregon Medical Power of Attorney

HEALTHCARE POWER OF ATTORNEY

(You do not have to fill out and sign this form.)

PART A: FACTS ABOUT COMPLETING THIS FORM

This is an important legal document. It can control critical decisions about your health care. Before signing, consider these important facts:

APPOINTING A HEALTH CARE REPRESENTATIVE: You have the right to name a person to direct your health care when you cannot do so. This person is called your "health care representative." You can do this by using Part B of this form. Your representative must accept on Part D of this form.

You can write in this document any restrictions you want on how your representative will make decisions for you. Your representative must follow your desires as stated in this document or otherwise made known. If your desires are unknown, your representative must try to act in your best interest. Your representative can resign at any time.

FACTS ABOUT COMPLETING THIS FORM. This form is valid only if you sign it voluntarily and when you are of sound mind. If you do not want a healthcare power of attorney, you do not have to sign this form.

Unless you have limited the duration of this healthcare power of attorney, it will not expire. If you have set an expiration date, and you become unable to direct your health care before that date this healthcare power of attorney will not expire until you are able to make those decisions again.

You may revoke this document at any time. To do so, notify your representative and your health care provider of the revocation.

Despite this document, you have the right to decide your own health care as long as you are able to do so.

If there is anything in this document that you do not understand, ask a lawyer to explain it to you.

Witnesses must sign Part C.

,

Unless revoked or suspended, this Healthcare Power of Attorney will continue for (initial one):

_____ My entire life

_____ Other period:

PART B: APPOINTMENT OF HEALTH CARE REPRESENTATIVE

I appoint , as my health care representative. My representative's address is , , , and telephone number is .

I appoint , as my alternate health care representative. My alternate's address is , , , and telephone number is .

I authorize my representative (or alternate) to direct my health care when I can't do so.

Note: You may not appoint your doctor, an employee of your doctor, or an owner, operator or employee of your health care facility, unless that person is related to you by blood, marriage or adoption or that person was appointed before your admission into the health care facility.

. LIMITS. Special conditions or instructions:

INITIAL IF THIS APPLIES:

_____ I have executed a Health Care Instruction or Directive to Physicians. My representative is to honor it.

. LIFE SUPPORT. "Life Support" refers to any medical means for maintaining life, including procedures, devices and medications. If you refuse life support, you will still get routine measures to keep you clean and comfortable.

INITIAL IF THIS APPLIES:

_____ My representative may decide about life support for me. (If you don't initial this space, then your representative may not decide about life support.)

. TUBE FEEDING. One sort of life support is food and water supplied artificially by medical device, known as tube feeding.

INITIAL IF THIS APPLIES:

_____ My representative may decide about tube feeding for me. (If you don't initial this space, then your representative may not decide about tube feeding.)

SIGN HERE TO APPOINT A HEALTH CARE REPRESENTATIVE:

Signature:___________________________________ Date: ____________

PART C: DECLARATION OF WITNESSES

We declare that the person signing this healthcare power of attorney:

(A) Is personally known to us or has provided proof of identity;

(B) Signed or acknowledged that person's signature on this healthcare power of attorney in our presence;

(C) Appears to be of sound mind and not under duress, fraud or undue influence;

(D) Has not appointed either of us as health care representative or alternative representative; and

(E) Is not a patient for whom either of us is attending physician.

Witnessed By:

Signature of Witness:________________________________________

Signature of Witness:________________________________________

NOTE: One witness must not be a relative (by blood, marriage or adoption) of the person signing this healthcare power of attorney. That witness must also not be entitled to any portion of the person's estate upon death. That witness must also not own, operate or be employed at a health care facility where the person is a patient or resident.

PART D: ACCEPTANCE BY HEALTH CARE REPRESENTATIVE

I accept this appointment and agree to serve as health care representative. I understand I must act consistently with the desires of the person I represent, as expressed in this healthcare power of attorney or otherwise made known to me. If I do not know the desires of the person I represent, I have a duty to act in what I believe in good faith to be that person's best interest. I understand that this document allows me to decide about that person's health care only while that person cannot do so. I understand that the person who appointed me may revoke this appointment. If I learn that this document has been suspended or revoked, I will inform the person's health care provider if known to me.

Signature of

Health Care Representative:________________________________________

Signature of Alternate