COLORADO MEDICAL DURABLE POWER OF ATTORNEY APPOINTMENT OF AGENT AND WHEN AGENT’S POWERS BEGIN ALTERNATES By this document, I intend to create a Medical Durable I, , Power of Attorney which shall take effect either (initial Declarant, hereby appoint: one): (Initials) Immediately upon my signature. Name of Agent (Initials) When my physician or other qualified medical professional has determined that I am unable to Agent’s Best Contact Telephone Number make my or express my own decisions, and for as long as I am unable to make or express my own decisions. Agent’s email or alternative telephone number INSTRUCTIONS TO AGENT Agent’s home address My Agent shall make healthcare decisions as I direct below, or as I make known to him or her in some other as my Agent to make and communicate my healthcare way. If I have not expressed a choice about the decision decisions when I cannot. This gives my Agent the power or healthcare in question, my Agent shall base his or her to consent to, or refuse, or stop any healthcare, decisions on what he or she, in consultation with my treatment, service, or diagnostic procedure. My Agent healthcare providers, determines is in my best interest. I also has the authority to talk with healthcare personnel, also request that my Agent, to the extent possible, get information, and sign forms as necessary to carry out consult me on the decisions and make every effort to those decisions. enable my understanding and find out my preferences. If the person named above is not available or is unable State here any desires concerning life-sustaining to continue as my Agent, then I appoint the following procedures, treatment, general care and services, person(s) to serve in the order listed below. including any special provisions or limitations: Name of Alternate Agent #1 Best Contact Telephone Number Agent’s email or alternative telephone number home address Name of Alternate Agent #2 Agent’s Best Contact Telephone Number Agent’s email or alternative telephone number My signature below indicates that I understand the purpose and effect of this document: Agent’s home address Signature of Declarant Date 1 Pursuant to Colorado Revised Statute 15-14.503–509
COLORADO MEDICAL DURABLE POWER OF ATTORNEY APPOINTMENT OF AGENT AND ALTERNATES I, , Declarant, hereby appoint: Name of Agent Agent’s Best Contact Telephone Number Agent’s email or alternative telephone number Agent’s home address as my Agent to make and communicate my healthcare decisions when I cannot. This gives my Agent the power to consent to, or refuse, or stop any healthcare, treatment, service, or diagnostic procedure. My Agent also has the authority to talk with healthcare personnel, get information, and sign forms as necessary to carry out those decisions. If the person named above is not available or is unable to continue as my Agent, then I appoint the following person(s) to serve in the order listed below. WHEN AGENT’S POWERS BEGIN By this document, I intend to create a Medical Durable Power of Attorney which shall take effect either (initial one): (Initials) Immediately upon my signature. (Initials) When my physician or other qualified medical professional has determined that I am unable to make my or express my own decisions, and for as long as I am unable to make or express my own decisions. INSTRUCTIONS TO AGENT My Agent shall make healthcare decisions as I direct below, or as I make known to him or her in some other way. If I have not expressed a choice about the decision or healthcare in question, my Agent shall base his or her decisions on what he or she, in consultation with my healthcare providers, determines is in my best interest. I also request that my Agent, to the extent possible, consult me on the decisions and make every effort to enable my understanding and find out my preferences. State here any desires concerning life-sustaining procedures, treatment, general care and services, including any special provisions or limitations: Name of Alternate Agent #1 Best Contact Telephone Number Agent’s email or alternative telephone number home address Name of Alternate Agent #2 Agent’s Best Contact Telephone Number Agent’s email or alternative telephone number Agent’s home address My signature below indicates that I understand the purpose and effect of this document: Signature of Declarant Date Pursuant to Colorado Revised Statute 15-14.503–509 1
co-medical-durable-power-of-attorney.docx