Create Durable Power of Attorney for Health Care Step 1 of 4 25% User Logged In?Contact InformationEmail* Already have an account?Login now.Principal InformationPrincipal's Name* First Last Principal's Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Agent InformationPrimary Agent Name* First Last Primary Agent Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Successor Agent InformationSuccessor Agent Name* First Last Successor Agent Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Agent PowersAgent Powers Select All Access to and control over all medical and personal information. To execute waivers, medical authorizations and such other documentation that may be required to permit or authorize my medical care or discontinue care. To make decisions that may allow my death. To give consent or refusal with respect to any medical care; diagnostic, surgical or therapeutic procedure; or other treatment of any type or nature, including life sustaining treatments such as artificial nutrition and hydration. To hire or discharge any medical personnel. Additional InstructionsAdditional Instructions* PDF Preview Full Screen Refresh Rotate your phone sideways for larger preview. Almost there! Complete secure checkout on the next page to receive your PDF without any watermarks or restrictions. Click "Previous" if you still have some edits to make. Lowest cost online Legally binding documents Instant PDF download Your data secure & private Step by step instructions $10.99 per form 100% Money-Back Guarantee We offer complete satisfaction guarantee on all Form Pros documents or your money back.