Durable Power of Attorney for Health Care, Michigan

MICHIGAN DURABLE POWER OF ATTORNEY

FOR HEALTH CARE

I, ________________________________________, am of sound mind and I voluntarily make this designation.

   (Print or type your full name)

APPOINTMENT OF PATIENT ADVOCATE

I designate ___________________________, my _________________________, living 

                   (Insert name of patient advocate)         (Spouse, child, friend)

at ____________________________________________________________________

   (Address of patient advocate)

as my patient advocate.

If my first choice cannot serve, I designate the person listed below as my patient advocate:

Successor Patient Advocate

Name:             ______________________________

Address:          _____________________________

Telephone

Number:          ______________________________

GENERAL POWERS OF PATIENT ADVOCATE

In making decisions for me, my patient advocate shall follow my wishes of which he or she is aware, whether expressed orally, in a living will, or in this durable power of attorney for health care.

My patient advocate or successor patient advocate shall have power to make care, custody, and medical treatment decisions for me if my attending physician and another physician or licensed psychiatrist or psychologist determine I am unable to participate in medical treatment decisions.

My patient advocate has authority to consent to or to refuse treatment on my behalf, to arrange medical and personal services for me, including admission to a nursing hospital or nursing 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, immediately upon signing an Acceptance.  This shall serve as a release under the Health Insurance Portability and Accountability Act.