Policy Manual sample

MDT Home Health Care Agency, Inc. DURABLE POWER OF ATTORNEY FOR HEALTHCARE WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document. Before executing this document, you should know these important facts: This document gives the person you designate as your agent (the attorney-in-fact) the power to make healthcare decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known. Except as you otherwise specify in this document, this document gives your agent the power to consent to your physician not giving treatment or stopping treatment necessary to keep you alive. Notwithstanding this document, you have the right to make medical and other healthcare decisions for yourself, so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection and healthcare necessary to keep you alive may not be stopped or withheld if you object at the time. This document gives your agent authority to consent, to refuse to consent or to withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition. This power is subject to any statement of your desires and any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your agent to make healthcare decisions for you if your agent: (1) authorizes anything that is illegal; (2) acts contrary to your known desires; or (3) where your desires are not known, does anything that is clearly contrary to your best interest. This power will exist for an indefinite period of time unless you limit its duration in this document. You have the right to revoke the authority of your agent, by notifying your agent or your treating physician, facility or other healthcare provider, orally or in writing of the revocation. Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document. Unless you otherwise specify in this document, this document gives your agent the power after you die to: (1) authorize an autopsy; (2) donate your body or parts thereof for transplant or therapeutic or education or scientific purposes; and (3) direct the disposition of your remains. Home Health Agency Miscellaneous M-4