Policy Manual sample

MDT Home Health Care Agency, Inc. DATE AND SIGNATURE OF PRINCIPAL (You must Date and Sign this Power of Attorney) I sign my name to this Statutory Form Durable Power of Attorney for Healthcare on the ______ day of __________________, _____ at __________________. Principal Signature: ___________________________________________ Witness Signature: ____________________________________________ Witness Signature: ____________________________________________ (This Power of Attorney will not be valid, unless it is signed by two qualified witnesses who are present when you sign or acknowledge your signature. If you have attached any additional pages to this form, you must date and sign each of the additional pages at the same time you date and sign this Power of Attorney.) Home Health Agency Miscellaneous M-8