NORTH CAROLINA ) DURABLE POWER OF ATTORNEY
_________________ COUNTY ) FOR HEALTH CARE
THE LAWS OF NORTH CAROLINA SHALL GOVERN THIS AGREEMENT IN ACCORDANCE
WITH CHAPTER 32A OF THE NORTH CAROLINA GENERAL STATUTES.
PRINCIPAL: ___________________________ (Print Name)
1. DESIGNATION OF HEALTH CARE AGENT
To my family, friends, physicians, health care providers, and community care facilities, and any other
person who may have an interest in my medical care:
I, ________________ (Principal’s Name Printed), being of sound mind, voluntarily create this Durable
Power of Attorney for Health Care and appoint _________________(Print Name of Agent), as my
agent. If __________________ _ cannot serve, I appoint ________________ (Print name Agent
Alternate), as my agent. If ___________ and or ________ cannot serve, I appoint Print name Agent
Alternate). Any person I have named as my agent will serve unless any of the following conditions
occur:
• I revoke his or her authority
• He or she becomes unavailable or unwilling to act as my agent, or
• He or she is my spouse or registered domestic partner and we commence proceedings for
Durable Power of Attorney for Health Care — Page 1
dissolution, annulment, or termination of the marriage or registered domestic partnership.
Contact information:
______________________ (Agent’s Printed name)
______________________ Address
______________________
______________________
______________________ Telephone
______________________ (Alternate’s Printed name)
______________________ Address
______________________
______________________
______________________ Telephone
______________________ (Alternate’s Printed name)
______________________ Address
______________________
______________________
______________________ Telephone
2. EFFECTIVENESS OF APPOINTMENT
Absent revocation, the authority granted in this document shall become effective when and if the
physician or physicians designated below determine that I lack sufficient understanding or capacity to
make or communicate decisions relating to my health care and will continue in effect during my
incapacity, until my death, except if I authorize my health care agent to exercise my rights with respect
to anatomical gifts, autopsy, or disposition of my remains, this authority will continue after my death to
the extent necessary to exercise the authority granted in this document for these purposes.
This determination shall be made by the following physician or physicians. For decisions related to
mental health treatment, this determination shall be made by the attending physician or eligible
psychologist, with decisions regarding my care in such circumstances be made by the Agent Kenneth D.
Faulkner.
3. GENERAL STATEMENT OF AUTHORITY GRANTED
Except as indicated in Section 4 below, I hereby grant to my health care agent named above full power
Durable Power of Attorney for Health Care — Page 2
and authority to make health care decisions, including mental health treatment decisions, on my behalf.
My agent's authority includes, but is not limited to, the following:
A. In accordance with the Health Insurance Portability and Accountability Act, and as my personal
representative, to request, review, and receive any information, verbal or written, regarding my
physical or mental health, including, but not limited to, medical and hospital records, and to
consent to the disclosure of this information.
B. To employ or discharge my health care providers.
C. To consent to and authorize my admission to and discharge from a hospital, nursing or
convalescent home, or other institution.
D. To consent to and authorize my admission to and retention in a facility for the care or treatment of
mental illness.
E. To consent to and authorize the administration of medications for mental health treatment and
electroconvulsive treatment (ECT) commonly referred to as "shock treatment."
F. To give consent for, to withdraw consent for, or to withhold consent for X-ray, anesthesia,
medication, surgery, and all other diagnostic and treatment procedures ordered by or under the
authorization of a licensed physician, dentist, or podiatrist. This authorization specifically
includes the power to consent to measures for relief of pain.
G. To take any lawful actions that may be necessary to carry out these decisions, including the
granting of releases of liability to medical providers.
4. SPECIAL PROVISIONS AND LIMITATIONS
In exercising the authority to make health care and mental health decisions on my behalf, the authority
of my health care agent is subject to the following special provisions and limitations:
X________ By initialing this paragraph, I expressly authorize my agent to make decisions to withhold
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or withdraw life-sustaining procedures, which would allow me to die, and I acknowledge such decisions
could or would allow my death.
X________ By initialing this paragraph, I expressly authorize my agent to make decisions to withhold
or withdraw artificially administered nutrition and hydration, which would allow me to die, and I
acknowledge such decisions could or would allow my death.
My agent shall make decisions for me in accordance with this Durable Power of Attorney for Health
Care, any instructions I give in my Declaration, and any other wishes to the extent known to my agent.
To the extent my wishes are unknown; my agent shall make decisions for me in accordance with what
my agent determines to be in my best interest. In determining my best interest, my agent shall consider
my personal values to the extent known to my agent.
5. AGENT'S POST-DEATH AUTHORITY
The authority of my agent shall continue after my death for a period of time sufficien