"Durable Power of Attorney Form for Health Care - Poudre Valley Hospital" - City of Fort Collins, Colorado

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Download "Durable Power of Attorney Form for Health Care - Poudre Valley Hospital" - City of Fort Collins, Colorado

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Poudre Valley Hospital
UNIVERSITY OF COLORADO HEALTH
Fort Collins, Colorado
I, ________________________________________________
BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE
PURPOSE AND EFFECT OF THIS DOCUMENT.
Hereby Appoint _____________________________________
I sign my name to this form on (date) ____________________
Name _____________________________________________
X ________________________________________________
Signature
Home Address ______________________________________
My current home address:
__________________________________________________
__________________________________________________
__________________________________________________
Phone: H____________________ W____________________
__________________________________________________
as my agent to make health care decisions for me if and when
Date of Birth: _______________________________________
I am unable to make my own health care decisions. This
gives my agent the power to consent to giving, withholding
WITNESSES
or stopping any health care, treatment, service, or diagnostic
procedure. My agent also has the authority to talk with health
I declare that the person who signed acknowledged this
care personnel, get information, and sign forms necessary to
document is personally known to me, that he/she signed or
carry out those decisions.
acknowledged this durable power of attorney in my presence,
and that he/she appears to be of sound mind and under
I hereby expressly authorize any physician, hospital and any
no duress, fraud, or undue influence. I am not the person
other person or organization to release and disclose to my
appointed as agent by this document, nor am I the patient’s
agent any information any of them may have concerning any
health care provider, or an employee of the patient’s health
treatment, diagnosis, recommendation or other facts which
care provider.
they may have concerning my physical condition and any
health care, counsel, treatment, or assistance provided to me
either before or after the execution of this power of attorney,
First Witness
any privilege hereby being expressly waived as to such
Signature: _________________________________________
disclosures.
Home Address: _____________________________________
If the person named as my agent is not available or is unable
__________________________________________________
to act as my agent, then I appoint the following person(s) to
Print Name: ________________________________________
serve in the order below.
Date: _____________________________________________
1.
Name _________________________________________
Second Witness
Home Address __________________________________
Signature: _________________________________________
______________________________________________
Home Address: _____________________________________
Phone: H_________________ W____________________
__________________________________________________
Print Name: ________________________________________
2.
Name _________________________________________
Date: _____________________________________________
Home Address __________________________________
______________________________________________
Patient Identification
Phone: H_________________ W____________________
By this document I intend to create a power of attorney for
health care which shall take effect upon my incapacity to make
my own health care decisions and shall continue during that
incapacity.
REV 12-06
01000200
E-461B
Scan to: Advanced Directives
Poudre Valley Hospital
UNIVERSITY OF COLORADO HEALTH
Fort Collins, Colorado
I, ________________________________________________
BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE
PURPOSE AND EFFECT OF THIS DOCUMENT.
Hereby Appoint _____________________________________
I sign my name to this form on (date) ____________________
Name _____________________________________________
X ________________________________________________
Signature
Home Address ______________________________________
My current home address:
__________________________________________________
__________________________________________________
__________________________________________________
Phone: H____________________ W____________________
__________________________________________________
as my agent to make health care decisions for me if and when
Date of Birth: _______________________________________
I am unable to make my own health care decisions. This
gives my agent the power to consent to giving, withholding
WITNESSES
or stopping any health care, treatment, service, or diagnostic
procedure. My agent also has the authority to talk with health
I declare that the person who signed acknowledged this
care personnel, get information, and sign forms necessary to
document is personally known to me, that he/she signed or
carry out those decisions.
acknowledged this durable power of attorney in my presence,
and that he/she appears to be of sound mind and under
I hereby expressly authorize any physician, hospital and any
no duress, fraud, or undue influence. I am not the person
other person or organization to release and disclose to my
appointed as agent by this document, nor am I the patient’s
agent any information any of them may have concerning any
health care provider, or an employee of the patient’s health
treatment, diagnosis, recommendation or other facts which
care provider.
they may have concerning my physical condition and any
health care, counsel, treatment, or assistance provided to me
either before or after the execution of this power of attorney,
First Witness
any privilege hereby being expressly waived as to such
Signature: _________________________________________
disclosures.
Home Address: _____________________________________
If the person named as my agent is not available or is unable
__________________________________________________
to act as my agent, then I appoint the following person(s) to
Print Name: ________________________________________
serve in the order below.
Date: _____________________________________________
1.
Name _________________________________________
Second Witness
Home Address __________________________________
Signature: _________________________________________
______________________________________________
Home Address: _____________________________________
Phone: H_________________ W____________________
__________________________________________________
Print Name: ________________________________________
2.
Name _________________________________________
Date: _____________________________________________
Home Address __________________________________
______________________________________________
Patient Identification
Phone: H_________________ W____________________
By this document I intend to create a power of attorney for
health care which shall take effect upon my incapacity to make
my own health care decisions and shall continue during that
incapacity.
REV 12-06
01000200
E-461B
Scan to: Advanced Directives