Short-Term Health Care Agent Authorization
Principal Information
Full Name
Address
Phone Number
Date of Birth
Health Care Agent Information
Agent Full Name
Agent Address
Agent Phone Number
Authorization Period
Start Date
End Date
Scope of Authorization
Describe the specific decisions or tasks authorized:
Special Instructions or Limitations
Principal Signature
Signature
Date
Witness or Notary (if required)
Witness/Notary Name
Signature
Date