Policy Manual sample

MDT Home Health Care Agency, Inc. DURABLE POWER OF ATTORNEY FOR HEALTHCARE Designation of Healthcare Agent. I, __________________ of __________________, do hereby designate and appoint __________________ of __________________, (___) __________________ as my Attorney-in-Fact (Agent) to make healthcare decisions for me as authorized in this document. (None of the following may be designated as your Agent: (1) your treating healthcare provider; (2) a non-relative employee of your treating healthcare provider; (3) an operator of a community care facility; (4) a non-relative employee of an operator of a community care facility; (5) an operator of a residential care facility for the elderly; or (6) a non-relative employee of an operator of a residential care facility for the elderly.) For the purposes of this document, "healthcare decision" means consent, refusal of consent or withdrawal of consent to any care, treatment, service or procedure to maintain, diagnose or treat an individual's physical or mental condition. · Creation of Durable Power of Attorney for Healthcare. By this document, I intend to create a Durable Power of Attorney for Healthcare under the state health license regulations affairs. This power of attorney is authorized by the Healthcare Agent Act and shall be construed in accordance with the provisions of the state health license regulations affairs.. This power of attorney shall not be affected by my subsequent incapacity. · General Statement of Authority Granted. Subject to any limitations in this document, I hereby grant to my Agent full power and authority to make healthcare decisions for me to the same extent that I could make such decisions for myself, if I had the capacity to do so. In exercising this authority, my Agent shall make healthcare decisions that are consistent with my desires, as stated in this document or otherwise made to my agent, including, but not limited to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services and procedures. (If you want to limit the authority of your Agent to make healthcare decisions for you, you can state the limitations ["Statement of Desires, Special Provisions and Limitations"] below. You can indicate your desires by including a statement of your desires in the same paragraph.) · Statement of Desires, Special Provisions and Limitations. (Your Agent must make healthcare decisions that are consistent with your known desires. You can, but are not required to, state your desires in the space provided below. You should consider whether you want to include a statement of your desires concerning other matters relating to your healthcare. You can also make your desires known to your Agent, by discussing your desires with your Agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit, in any other way, the authority given your Agent by this document, you should state the limits in the space below. If you do not state any limits, your Agent will have broad powers to make healthcare decisions for you, except to the extent that there are limits provided by law.) In exercising the authority under this Durable Power of Attorney for Healthcare, my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated below: Home Health Agency Miscellaneous M-6