I, _________________, domiciled in_____________________, hereby designate _________, as my health care surrogate to make any health care decisions for me when I no longer have decisional capacity. Any prior designation is revoked.

If, at any time, it appears that I am unable to care for myself and that it is appropriate that I be placed in a long-term facility, before placing me in such a facility, my health care surrogate shall obtain statements from my attending and one (1) other physician to the effect that, in their professional medical opinions, the condition of my health is of the nature and duration that I should be placed in a long-term care facility which is certified to administer the proper care over my health. If my attending and one (1) other physician, in their professional medical opinions, thereafter make a determination that the condition of my health has improved so that I can care for myself, then, in such event, my health care surrogate shall assist me in being removed from the long-term care facility and returned to a residential setting.

In addition to the rights given my health care surrogate above, I grant my health care surrogate the follows:

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1. My health care surrogate shall have the ability to control and provide for my personal care needs as follows:

(a) To do all acts to maintain my customary standard of living, to provide for my living place through purchase, lease or other method, to provide domestic help with either skilled or non-skilled help and to compensate, hire and dismiss such person;

(b) To provide for me opportunities for recreation, physical exercise, therapy and to arrange travel in accordance with such needs;

(c) To provide for my spiritual care; and

(d) To take care of my person in case of sickness or disability of any kind, including the removal of or placement in any such institution or place as may be deemed best by my health care surrogate for my personal care and comfort.

2. My health care surrogate is authorized to provide for my health and medical care needs. My health care surrogate will receive my instructions if I am able to participate in those decisions; and if I cannot participate, in my health care surrogate??™s sole discretion, then my health care surrogate shall carry out my instructions as follows:

(a) To receive and review proposed medical treatment and to make sole decisions concerning such treatment.

(b) To authorize and consent to any medical treatment and/or surgical procedure, irrespective of the degree of risk or danger involved;

(c) To employ and discharge such health providers, including but not limited to any physicians, nurses, psychiatrists, dentists and therapists.

I further direct that this designation shall take effect as below provided and shall be irrevocable except as herein otherwise expressly stated.

This designation shall become effective on the date of execution hereof and shall continue effective until it is revoked by me in writing. This designation, as between said health care surrogate and me, may be revoked at any time by prior written notice to said health care surrogate stating the date on which such revocation shall be effective; BUT, with regard to any revocation by me or by operation of law, including death, anyone else in good faith relying upon the exercise of these powers by said health care surrogate may rely upon this instrument for its continuing validity. This instrument may be recorded in a public office but need not necessarily be so recorded.


My said health care surrogate shall not be liable for any loss sustained through error of judgment made in good faith, but said co-health care surrogates shall be liable for willful misconduct or breach of good faith.

IN WITNESS WHEREOF, I have hereunto set my hand, this the ________ day of _____________, 201_____.


…SCT )

Before me, the undersigned authority, came the Grantor, __________________, who is of sound mind and eighteen (18) years of age, or older, and acknowledge that s/he voluntarily dated and signed this writing or directed it to be signed and dated as above.

Dated, this the ________ day of __________________, 201____.

Commission: ________________________


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