WILLIAM DONALD SCHAEFER, Governor                           S.B. 664

THE FOLLOWING FORM MAY BE USED TO GIVE HEALTH CARE INSTRUCTIONS,
TO CREATE A POWER OF ATTORNEY FOR HEALTH CARE, OR BOTH. THIS FORM IS
NOT INTENDED TO BE EXCLUSIVE, DIFFERENT FORMS MAY BE USED, AND AN
INDIVIDUAL USING THIS FORM MAY COMPLETE BOTH PARTS OF THE FORM OR
ONLY ONE PART.

ADVANCE MEDICAL DIRECTIVE

APPOINTMENT OF HEALTH CARE AGENT
(OPTIONAL FORM)

(CROSS THROUGH IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE HEALTH
CARE DECISIONS FOR YOU.)

(1) I,                                                                                 RESIDING AT

APPOINT THE FOLLOWING INDIVIDUAL AS MY AGENT TO MAKE HEALTH CARE
DECISIONS FOR ME:                                                                                                           

(FULL NAME, ADDRESS AND TELEPHONE NUMBER)

OPTIONAL: IF THIS AGENT IS NOT REASONABLY AVAILABLE OR IS UNABLE OR
UNWILLING TO ACT AS MY AGENT, THEN I APPOINT THE FOLLOWING PERSON TO
ACT IN THIS CAPACITY.                                                                                                     

(FULL NAME, ADDRESS AND TELEPHONE NUMBER)

(2)     MY AGENT HAS FULL POWER AND AUTHORITY TO MAKE HEALTH CARE
DECISIONS FOR ME, INCLUDING THE POWER TO:

1.           REQUEST, RECEIVE, AND REVIEW ANY INFORMATION, VERBAL OR

WRITTEN, REGARDING MY PHYSICAL OR MENTAL HEALTH,
INCLUDING, BUT NOT LIMITED TO, MEDICAL AND HOSPITAL
RECORDS, AND CONSENT TO DISCLOSURE OF THIS INFORMATION;

2.          EMPLOY AND DISCHARGE MY HEALTH CARE PROVIDERS;

3.          AUTHORIZE MY ADMISSION TO OR DISCHARGE FROM (INCLUDING

TRANSFER TO ANOTHER FACILITY) ANY HOSPITAL, HOSPICE,
NURSING HOME, ADULT HOME, OR OTHER MEDICAL CARE
FACILITY; AND

4.          CONSENT TO OR REFUSE THE PROVISION OF ANY TYPE OF HEALTH

CARE INCLUDING LIFE PROLONGING PROCEDURES.

(3)    IN EXERCISING THE AUTHORITY UNDER THIS DURABLE POWER OF ATTORNEY
FOR HEALTH CARE, THE AUTHORITY OF MY AGENT IS SUBJECT TO THE FOLLOWING
SPECIAL PROVISIONS AND LIMITATIONS:

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