Durable Medical Power Of Attorney Form



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A witness shall not sign this Durable Power of Attorney unless the person appears to be of sound mind and under no duress, fraud or undue influence.) Names and Addresses of Witnesses: (Witness 1 Name) ( Witness 1 Address) (Witness 1 Signature) (Witness 2 Name) (Witness 2 Address) 

A witness must be a disinterested individual and may not be the person’s spouse, parent, child, grandchild, sibling, presumptive heir, known devisee at the time of the witnessing, physician, patient advocate, an employee of a life or health insurance provider for the patient, an employee of a health facility that is treating the patient, or an employee of a home for the aged.)

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