North Dakota Health Care Power of Attorney Form - Free Download | Page 4
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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(If you want to limit the authority of your agent to receive and disclose information
relating to your health, you must state the limitations in paragraph 4 above.)
6. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to
implement the health care decisions that my agent is authorized by this document to
make, my agent has the power and authority to execute on my behalf all of the
following:
a. Documents titled or purporting to be a "Refusal to Permit Treatment" and
"Leaving Hospital Against Medical Advice".
b. Any necessary waiver or release from liability required by a hospital or
physician.
7. DURATION. (Unless you specify a shorter period in the space below, this power of
attorney will exist until it is revoked.)
This durable power of attorney for health care expires on
_______________________________________________________________
(Fill in this space ONLY if you want the authority of your agent to end on a specific
date.)
8. DESIGNATION OF ALTERNATE AGENTS. (You are not required to designate any
alternate agents but you may do so. Any alternate agent you designate will be able
to make the same health care decisions as the agent you designated in paragraph 1,
above, in the event that agent is unable or ineligible to act as your agent. If the
agent you designated is your spouse, he or she becomes ineligible to act as your
agent if your marriage is dissolved. Your agent may withdraw whether or not you
are capable of designating another agent.)
If the person designated as my agent in paragraph 1 is not available or
becomes ineligible to act as my agent to make a health care decision for me or loses
the mental capacity to make health care decisions for me, or if I revoke that person's
appointment or authority to act as my agent to make health care decisions for me,
then I designate and appoint the following persons to serve as my agent to make
health care decisions for me as authorized in this document, such persons to serve in the
order listed below:
a. First Alternate Agent: ____________________________________________
______________________________________________________________
(Insert name, address, and telephone number of first alternate agent.)
b. Second Alternate Agent: _________________________________________
______________________________________________________________
