OF [Name of Declarant] Pursuant to the Arkansas Durable Power of Attorney for Health Care Act (Ark. Code Ann. § 20- 13-104) (the I hereby designate and appoint as my agent, or “Act”), attorney in fact, to make decisions regarding my health care during periods when my health care provider has determined that I lack capacity to decide for myself. Specifically, and not to limit any other rights prescribed under the Act, my attorney-in-fact shall have the power to have access to my medical records for treatment or payment decisions; to disclose medical records to others for purposes of treatment, payment, or health care operations; to employ and discharge physicians; to consent to or refuse to consent to medical procedures, including the withholding or withdrawal of life-sustaining treatment, and nutrition and hydration, according to my wishes expressed in my Living Will, or, if my wishes are unclear under the then existing circumstances of my medical condition, then upon consideration of my best interests as determined by my physician in consultation with my agent; to admit me to hospitals, including psychiatric hospitals, nursing homes, or hospice care; and to sign all appropriate forms, consents and releases in connection with any of said matters. If resigns, or is not able or available to make health care decisions for me, or if an named by me is divorced from me or is my spouse and legally separated from me, I appoint as successor, with all of the rights and powers and authority herein stated. The term care” shall have the meaning set forth in Ark. Code Ann. § “health 20-13-104(c). This Durable Power of Attorney for Health Care shall not be affected by my subsequent disability or incapacity. SIGNED this day of , 20_ . Signature We, the undersigned, do hereby certify that the Declarant, subscribed this Durable Power of Attorney for Health Care in our presence, and we, at his or her request, in his or her presence, and in the presence of each other, signed as attesting witnesses, and we do further certify that the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without undue influence, fraud or restraint and that his or her signature was voluntary. Witness Witness Address Address City, State and Zip Code City, State and Zip Code
OF [Name of Declarant] Pursuant to the Arkansas Durable Power of Attorney for Health Care Act (Ark. Code Ann. § 20- 13-104) (the “Act”), I hereby designate and appoint as my agent, or attorney in fact, to make decisions regarding my health care during periods when my health care provider has determined that I lack capacity to decide for myself. Specifically, and not to limit any other rights prescribed under the Act, my attorney-in-fact shall have the power to have access to my medical records for treatment or payment decisions; to disclose medical records to others for purposes of treatment, payment, or health care operations; to employ and discharge physicians; to consent to or refuse to consent to medical procedures, including the withholding or withdrawal of life-sustaining treatment, and nutrition and hydration, according to my wishes expressed in my Living Will, or, if my wishes are unclear under the then existing circumstances of my medical condition, then upon consideration of my best interests as determined by my physician in consultation with my agent; to admit me to hospitals, including psychiatric hospitals, nursing homes, or hospice care; and to sign all appropriate forms, consents and releases in connection with any of said matters. If resigns, or is not able or available to make health care decisions for me, or if an named by me is divorced from me or is my spouse and legally separated from me, I appoint as successor, with all of the rights and powers and authority herein stated. The term “health care” shall have the meaning set forth in Ark. Code Ann. § 20-13-104(c). This Durable Power of Attorney for Health Care shall not be affected by my subsequent disability or incapacity. SIGNED this day of , 20_ . Signature We, the undersigned, do hereby certify that the Declarant, subscribed this Durable Power of Attorney for Health Care in our presence, and we, at his or her request, in his or her presence, and in the presence of each other, signed as attesting witnesses, and we do further certify that the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without undue influence, fraud or restraint and that his or her signature was voluntary. Witness Witness Address Address City, State and Zip Code City, State and Zip Code