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or incapable of making health care decisions for myself. I understand the role of health care professionals in my health care decision making. I authorize (Print Name) (Print Full Name) (Print Full Name) (State of Ohio Health Care Power of Attorney of (Print Full Name) (Birth Date) to make certain health care decisions for me. The duties of this Power of Attorney are: If I am ill, I want my health care providers to care for me and my family at no cost to me I want my health care providers to make sure my prescriptions and medical supplies are available and appropriate for me I want my health care providers to coordinate my care with other health care providers I want my health care providers to refer me and to provide me or my family with health care services that are appropriate to my needs I want my health care providers to monitor my health care status I want my health care providers to make reasonable efforts to keep me informed about my health care I want my health care providers to make reasonable attempts to work with me and my family and to help us make informed decisions about our health care I want my health care providers to help me manage and control chronic health care problems and chronic illnesses I want my health care providers to assist me and my family in making informed medical and health care decisions that are in my and my family's best interests I want my health care providers to help me in making decisions about health I want my health care providers to have no problem working with my child's doctor and in collaborating with my child's doctor I want my health care providers to provide me with the services that are most effective in treating my illness (e.g., blood thinners) I want my health care providers to make sure that I and my family are receiving the appropriate medical and mental health services (e.g., treatment for substance abuse or other mental health problems) I want my health care providers to provide me with treatment for any conditions that could result in my incarceration and/or my death, including, but not limited to, conditions resulting in death (e.g., cancer) I want my health care providers to be able to prescribe the right medications to help me manage my illness(s) and my symptoms I want my health care providers to make sure that I and my family receive any medical care directed to me by Medicare, Medicaid, Children's Health Insurance Program, Veterans Affairs, Medicare prescription drug

Ohio Durable Power of Attorney for Health Care Form allows a person to grant power to make health care decisions on behalf of the issuing principal when that principal is incapacitated and unable to do so (pursuant to Chapter 1337.17 of the Ohio Revised Code).