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Michigan ________________________________________________________ (Address of successor Patient Advocate) -6- durable power of attorney for health care on the following date ______________. Signed: _____________________________ (Signature of successor patient advocate) Dated: ________________ __________________, (Name of successor patient advocate) understand the above conditions and I accept the designation as patient advocate for _______________________________________ (Name of patient), who signed a d: ________________ ______________________________________________________________________ (Address of Patient Advocate) SIGNATURE OF SUCCESSOR PATIENT ADVOCATE I, ______________________________________________ (Name of patient), who signed a durable power of attorney for health care on the following date ______________. Signed: _____________________________ (Signature of patient advocate) Date PATIENT ADVOCATE I, ______________________________________, (Name of patient advocate) understand the above conditions and I accept the designation as patient advocate for ___________________________health facility or agency has the rights enumerated in Section 20201 of the Public Health Code, Act No. 368 of Public Acts of 1978, being Section 333.20201 of the Michigan Compiled Laws. SIGNATURE OFnt to revoke. -5- (h) A patient advocate may revoke his or her acceptance to the designation at any time and in any manner sufficient to communicate an intent to revoke. (i) A patient admitted to a ipate in medical treatment decisions are presumed to be in the patient's best interests. (g) A patient may revoke his or her designation at any time and in any manner sufficient to communicate an inteicable to fiduciaries when acting for the patient and shall act consistent with the patient's best interest. The known desires of the patient expressed or evidenced while the patient is able to particrsed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities. (f) A patient advocate shall act in accordance with the standards of care applr would allow the patient's death. (e) A patient advocate shall not receive compensation for the performance of his or her authority, rights, and responsibilities, but a patient advocate may be reimbuo die only if the patient has expressed in a clear and convincing manner that the patient advocate is authorized to make such a decision, and that the patient acknowledges that such a decision could ow treatment from a patient who is pregnant that would result in the pregnant patient's death. (d) A patient advocate may make a decision to withhold or withdraw treatment which would allow a patient tient, if the patient were able to participate in the decision, could not have exercised on his or her own behalf. (c) This designation cannot be used to make a medical treatment to withhold or withdra unless the patient is unable to participate in medical treatment decisions. (b) A patient advocate shall not exercise powers concerning the patient's care, custody, and medical treatment that the patvocate (and successor patient advocate, if one is named) accepts the Principal's designation and appointment as stated in this document and agrees that: (a) This designation shall not become effective____ Print name here: __________________________________ Address: __________________________________ __________________________________ ACCEPTANCE BY PATIENT ADVOCATE By signing below, the patient ad_____________ Print name here: __________________________________ Address: __________________________________ __________________________________ Signature of witness 2: ______________________________s instrument, nor are we an employee of a home for the aged where the person who signed this instrument resides. We are at least eighteen years old. -4- Signature of witness 1: _____________________te or a Successor Patient Advocate in this document. Nor are we an employee of a life or health insurance provider for, or an employee for a health facility that is treating, the person who signed thime of witnessing of the person who signed this instrument. We are not entitled to any portion of John Doe's estate according to the laws of Intestate Succession. We are not named as the Patient Advocaus to be of sound mind and under no duress, fraud or undue influence. We are not the spouse, parent, child, grandchild, sibling, physician, presumptive heir, or known beneficiary of the will at the tiwithout duress, fraud or undue influence. We declare that the person who signed this Document, is personally known to us, that he/she signed this document in our presence, and that he/she appeared to STATEMENT AND SIGNATURE OF WITNESSES We sign below as witnesses. This declaration was signed in our presence. The declarant appears to be of sound mind, and to be making this designation voluntarily, e not your spouse, child, grandchild, brother or sister, an employee of a company through which you have life or health insurance, or an employee at the health care facility where you are a patient. _______ _______________________________________________________________________ NOTICE REGARDING WITNESSES You must chose two adult witnesses who will not receive your assets when you die and who arr responsibilities as my patient advocate. SIGNATURE I sign this document voluntarily, and I understand its purpose. Signed: (Address) __________________________________ (Your signature) Dated: ____d to compensation for services performed under this power of attorney, but he or she shall be entitled to reimbursement for actual and necessary expenses incurred as a result of carrying out his or hes document be followed and be considered conclusive evidence of my wishes. -3- Photocopies of this document can be relied upon as though they were originals. My patient advocate shall not be entitle estate. If I am unable to participate in making decisions for my care and there is no patient advocate or successor patient advocate to act for me, I request that the instructions I have given in thiinstructions of my patient advocate or successor patient advocate pursuant to this document, without actual notice that this power has been revoked or amended, shall incur any liability to me or to my in any particular circumstance. I may change my mind at any time by communicating in any manner that this designation does not reflect my wishes. No person or entity that relies in good faith on the ___________________________ OR B. I choose not to express any wishes in this document. This choice shall not be interpreted as limiting the power of my patient advocate to make any particular decision___________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________________________ _______________________________________________________________ _______________________________________________________________ ____________________________ treatment I do or not want in such circumstances; or I may state no wishes at all. A. My wishes are as follows (you may attach additional sheets of paper) (if none, write "none") ____________________inue care that I am receiving. In this document, I can express general wishes regarding conditions such as terminal illness, permanent unconsciousness, or other disability; specify particular types ofrocedure; or other treatment of any type or nature. D. To execute waivers, medical authorizations and such other approval as may be required to permit or authorize care which I may need, or to discontiders, and to pay them reasonable compensation with my funds; C. To give an informed consent or an informed refusal on my behalf with respect to any medical care; diagnostic, surgical or therapeutic py of my person, including by not limited to: A. To have access to and control over my medical and personal information; B. To employ and discharge physician, nurses, therapists and any other care provin a wide variety of circumstances. With respect to my care, custody and medical treatment, my advocate shall have the power to make each and every judgment for the proper and adequate care and custod_______________________________________________ (Sign your name if you wish to give your patient advocate this authority) -2- STATEMENT OF WISHES My patient advocate has authority to make decisions (OPTIONAL) I expressly authorize my patient advocate to make decisions to withhold or withdraw treatment, which would allow me to die, and I acknowledge such decisions could or would allow my death. _ursing care facility, and to pay for such services with my funds. My patient advocate shall have access to any of my medical records to which I have a right. POWER REGARDING LIFE-SUSTAINING TREATMENT will, or in this designation. My patient advocate has authority to consent to or refuse treatment on my behalf, to arrange medical and personal services for me, including admission to a hospital or nable to participate in making my own medical decisions. In making decisions, my patient advocate shall endeavor to follow my previously expressed wishes, whether I have stated them orally, in a livingth Care shall remain in effect until my death, revocation or termination by law. My attending physician and another physician or licensed psychologist shall determine, after examining me, when I am unrney for Health Care shall become effective only in the event that I am unable to participate in decisions about my own medical treatment. Unless revoked by me, this Durable Power of Attorney for Healccessor patient advocate if he or she is unable to act. This is a durable power of attorney and its validity shall not be affected by my subsequent disability or incapacity. This Durable Power of Attoient advocate) to serve as my successor patient advocate. My patient advocate or successor patient advocate (collectively referred to as patient advocate) may delegate his or her powers to the next su____, (relation i.e. spouse, child, friend ...) living at ____________________________________________ _______________________________________________________________________ (Address of successor patt advocate does not accept, is incapacitated, resigns, is removed or cannot serve, I designate _________________________________________ (Name of successor patient advocate) my _______________________ child, friend ...) living at _______________ _______________________________________________________________________ (Address of patient advocate) as my patient advocate. If my first choice as patienint or type your full name), am of sound mind and I voluntarily make this designation. I designate _____________________________ (name of patient advocate), my _________________ (relation i.e. spouse,rchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Durable Power Of Attorney For Health Care I, _____________________________________________ (Pring this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. The pu advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signMichigan Durable Power Of Attorney For Health Care This is a Durable Power Of Attorney For Health Care for use in the State of Michigan. These forms are not intended and are not a substitute for legal Michigan