IDAHO DURABLE POWER OF ATTORNEY FOR HEALTH CARE

1. Designation of Health Care Agent - I, ______________________________, do hereby designate and

appoint________________________________________________________________________(name, address and

telephone number), as my attorney in fact (agent) to make health care decisions for me as authorized in this document.

For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent

to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical condition.

2. Creation of Durable Power of Attorney for Health Care - By this document I intend to create a durable

to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures.

4. Statement of Desires, Special Provisions, and Limitations - (You can, but are not required to, state your

desires below.) In exercising the authority under this durable power of attorney for health care, my agent shall act

consistently with my desires as stated below and is subject to the special provisions and limitations stated in the living

will. Additional statement of desires, special provisions, and limitations:

{a}

{b}

{c}

{c} Consent to the disclosure of this information;

{d} Consent to the donation of any of my organs for medical purposes. (This statement should be crossed

out if organ donation is not desired)

6. Signing Documents, Waivers, and Releases - Where necessary to implement the health care decisions

that my agent is authorized by this document to make, my agent has the power and authority to execute on my behalf

all of the following:

{a} Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against

Medical Advice."

{b} Any necessary waiver or release from liability required by a hospital or physician.

First Alternative Agent Second Alternative Agent

Name: Name:

Address: Address:

Telephone: Telephone:

8. Prior Designations Revoked - I revoke any prior durable power of attorney for health care.

9. Law That Governs - This durable power of attorney for health care is made by me as an Idaho resident.

This instrument is in the document form prescribed by Idaho Code Section 39-4505 and shall be governed by the Idaho

10. Signature - I sign my name to this Statutory Form Durable Power of Attorney for Health Care on the _____

day of __________________ in the year _______ , at _______________________ , ______________ .

______________________

(signature)

I declare under penalty of perjury under the laws of Idaho that the person who signed or acknowledged this

document is personally known to me (or proved to me on the basis of convincing evidence) to be the principal, that the

principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of

sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as attorney in fact by

this document, and that I am not a health care provider, an employee of a health care provider, the operator of a

community care facility, nor an employee of an operator of a community care facility.

I further declare under penalty of perjury under the laws of the State of Idaho that I am not related to the

principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of

the principal upon the death of the principal under a will now existing or by operation of law.

Address: Address:

(Notary Option)

STATE OF IDAHO }

: ss

County of _________ }

On this _______ day of _____________________ , in the year ________ , before me personally appeared

_____________________________

Notary Public for the State of Idaho

My Commission Expires: