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Name Medical record # DURABLE POWER OF ATTORNEY FOR HEALTH CARE Notice to Person Executing This Document This is an important legal document. Before executing this document you should know these facts:

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2. Step 2: Read the instructions carefully to understand the purpose and requirements of the document.
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4. Step 4: Provide accurate and complete information to ensure the document is filled out correctly.
5. Step 5: Double-check all the entered information for any errors or omissions.
6. Step 6: If there are any sections or fields that you are unsure about, seek clarification or assistance from the relevant authorities or professionals.
7. Step 7: Review the completed document to ensure all necessary sections are filled out and all required attachments or supporting documents are attached.
8. Step 8: Sign and date the document as instructed.
9. Step 9: Make copies of the completed document for your records, if necessary.
10. Step 10: Submit the filled-out document according to the specified instructions or to the appropriate recipient.

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