DURABLE MEDICAL POWER OF ATTORNEY

STATE OF __________

1. APPOINTMENT OF PRIMARY HEALTHCARE AGENT

I, __________, born on __________, residing at __________, __________, __________ __________, __________ (Phone: __________), hereby appoint the following individual as my attorney-in-fact ("Primary Healthcare Agent"):

Name: __________
Relationship: __________
Phone: __________
Address: __________, __________, __________ __________, __________

to make any and all healthcare decisions on my behalf in accordance with the laws of the State of __________.

3. DURABILITY & EFFECTIVE DATE

This Medical Power of Attorney is DURABLE and shall not be affected by my subsequent disability, incompetence, or incapacity. This document becomes effective upon a written determination by my attending physician that I lack legal capacity to make or communicate informed healthcare decisions.

4. POWERS GRANTED TO HEALTHCARE AGENT

My Healthcare Agent is authorized to make all healthcare decisions for me, including but not limited to the following granted powers:

6. AGENT ELIGIBILITY & REVOCATION

I confirm that my named agent(s) are eligible to serve under state law. I hereby revoke any prior Medical Power of Attorney or Healthcare Proxy instruments executed by me.

IN WITNESS WHEREOF, I have executed this Medical Power of Attorney on __________.

WITNESS ATTESTATION STATEMENT

The Principal signed this instrument in our presence. We affirm that the Principal appears to be of sound mind and free from duress, fraud, or undue influence.

NOTARY PUBLIC ACKNOWLEDGMENT

State of __________, County of _______________________

On this date, before me, the undersigned Notary Public, personally appeared __________, known to me (or satisfactorily proven) to be the person who executed the foregoing Medical Power of Attorney.