North Dakota Health Care Power of Attorney Form - Free Download | Page 2
The North Dakota health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.
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You should carefully read and follow the witnessing procedure described at the end of
this form. This document will not be valid unless you comply with the witnessing
If there is anything in this document that you do not understand, you should ask a lawyer
to explain it to you.
Your agent may need this document immediately in case of an emergency that requires a
decision concerning your health care. Either keep this document where it is immediately
available to your agent and alternate agents, if any, or give each of them an executed copy
of this document. You should give your doctor an executed copy of this document.
1. DESIGNATION OF HEALTH CARE AGENT. I, ____________________________
(insert your name and address)
do hereby designate and appoint: ______________________________________
(insert name, address, and telephone number of one individual only as your agent to
make health care decisions for you. None of the following may be designated as
your agent: your treating health care provider, a nonrelative employee of your
treating health care provider, an operator of a long-term care facility, or a nonrelative
employee of an operator of a long-term care facility) as my attorney in fact (agent) to
make health care decisions for me as authorized in this document. For the
purposes of this document, "health care 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.
2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this
document I intend to create a durable power of attorney for health care.
3. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in
this document, I hereby grant to my agent full power and authority to make health
care 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
health care decisions that are consistent with my desires as stated in this document
or otherwise made known to my agent, including 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 health care decisions for you,
you can state the limitations in paragraph 4 below. You can indicate your desires by
including a statement of your desires in the same paragraph.)
4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. (Your
agent must make health care decisions that are consistent with your known desires.