1. At the top of the form, print your name and address. Print the name, address, and phone number of the person you choose as your Health Care Agent. (Optional: You may name a second person as an alternate. Your alternate will be called if your agent is unable or unwilling to serve
2. Setting limits on your agent’s authority might make it difficult for your agent to act for you in an unexpected situation. If you want an agent to have full authority to act for you, leave the limitations space blank.
3. BEFORE you sign, be sure you have two adults present who can witness you signing the document. The only people who cannot serve as witnesses are your Agent and Alternate. Then sign the document yourself (or if you are physically unable, have someone else sign at your direction The person who signs your name for you should put his or her name and address in the spaces provided.
4.Have your witness fill in the date, sign their names, and print their names and addresses.
5.OPTIONAL: On the back of the form are statements to be signed by your Agent and any alternate. This is not required by law but is recommended to ensure that you have talked with the person or persons who may have to make important decisions about your care and that each of them realizes the importance of the task they may have to do.