Policy Manual sample

MDT Home Health Care Agency, Inc. DURABLE POWER OF ATTORNEY FOR HEALTHCARE (continued) · Statement of desires concerning life-prolonging care, treatment, services and procedures: · Additional statement of desires, special provisions and limitations: (You may attach additional pages, if you need more space to complete your statement. If you attach additional pages, you must date and sign EACH of the additional pages at the same time you date and sign this document. · Duration. (Unless you specify otherwise in the space below, this power of attorney will exist for an indefinite period of time.) · Prior Designations Revoked. I revoke any prior Durable Power of Attorney for Healthcare. Home Health Agency Miscellaneous M-7