October 10, 2085

Dr. Alfonso Jewel

Springfield Medical Center

456 Oak Avenue

Springfield, IL 62701

Dear Dr. Jewel,

I, [Your Name], born on June 15, 1950, hereby appoint Jacklyn Lockman, residing in Knoxville, TN 37901, as my authorized healthcare representative. This letter serves as official notice of my authorization for Jacklyn Lockman to act on my behalf in matters related to my healthcare, including but not limited to making decisions about my medical treatment, accessing my medical records, and communicating with healthcare professionals and insurance companies concerning my care.

Scope of Authority
This authorization includes the following powers granted to my healthcare representative:

• To make healthcare decisions on my behalf if I am unable to do so.

• To access and discuss my medical records and history with healthcare providers.

• To communicate with my insurance provider, Greenway Health Insurance, regarding my health coverage and benefits.

• To make decisions regarding the continuation or cessation of medical treatment if I am incapacitated.

Duration of Authorization
This authorization is valid from October 10, 2085, and will remain in effect until October 10, 2086, or until I revoke it in writing, whichever comes first. If I am unable to revoke this authorization due to my health condition, this letter will remain in effect until I am capable of doing so.

I understand that this letter allows my representative to make decisions as though I were making them myself and that all decisions made by my representative will be binding upon me.

I affirm that I am of sound mind and that I am voluntarily appointing Jacklyn Lockman as my healthcare representative.

Patient’s Signature:

John Doe
October 10, 2085

Witness:

Emmy Green
October 10, 2085

Notary (if applicable):

Notary Public: Thomas Green
October 10, 2085

[Seal]

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