Healthcare Power of Attorney

# Healthcare Power of Attorney **Principal Full Legal Name:** ___________ **Principal Date of Birth:** ___________ **Principal Address:** ___________ **State of Domicile:** ___________ --- I, ___________ ("Principal"), hereby designate and appoint the following individual as my Healthcare Agent to make healthcare decisions on my behalf as set forth in this Healthcare Power of Attorney. ## Article I — Designation of Healthcare Agent **Healthcare Agent:** ___________ **Agent Address:** ___________ **Agent Phone:** ___________ **Agent Email:** ___________ **Relationship to Principal:** ___________ **Successor Healthcare Agent:** ___________ **Successor Agent Address:** ___________ **Successor Agent Phone:** ___________ If the primary Healthcare Agent is unable or unwilling to serve, or if the primary Agent's appointment is revoked, the Successor Healthcare Agent shall serve with the same authority. ## Article II — Effectiveness This Healthcare Power of Attorney becomes effective when my attending physician and one other physician or licensed psychologist determine and attest in writing that I lack the capacity to make or communicate healthcare decisions for myself. If I subsequently regain capacity, this Power of Attorney shall become ineffective until such time as I again lack capacity. ## Article III — Authority of Healthcare Agent