Fillable MEDICAL POWER OF ATTORNEY

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MEDICAL POWER OF ATTORNEY

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PowerofAttorney.com
Page 1 of 5
MEDICAL POWER OF ATTORNEY
IMPORTANT INFORMATION
IT IS IMPORTANT THAT YOU REVIEW THE FOLLOWING INFORMATION BEFORE
YOU SIGN THIS DOCUMENT. READ THE INFORMATION CAREFULLY AND SEEK
GUIDANCE FROM A HEALTHCARE PROFESSIONAL OR ATTORNEY IF YOU DO
NOT UNDERSTAND ANY OF THE TERMS.
By signing this document, you are giving authority to the person you are designating as
your agent to make medical decisions on your behalf. Medical decisions can include
any medical service, treatment, medical procedure, diagnosis or treat both mental and
physical conditions. Your agent will be able to act with the same authority you would
have if you were able to act for yourself and will have the authority to consent, refuse to
consent to medical treatment including decisions about withdrawing or withholding life-
sustaining treatment. It is, therefore, important that you know and trust your agent and
that your agent is aware of your preferences for health care treatment.
Even after you sign this document, you will still be able to make your health care
decisions assuming you are still considered mentally competent. Your agent cannot act
on your behalf until your physician has determined that you are no longer physically or
mentally able to make medical decisions.
The person you choose as your agent must be at least eighteen years old and someone
that you trust with your health care. Your agent is not liable for any decisions they make
on your behalf, as long as those decisions were made in good faith. You should make
sure that you have chosen agent wants to take on the role as agent. Discuss your
medical preferences with your agent so they are aware of your wishes. Review this
document with your agent so they are aware of their role. You also may choose a back-
up agent in case your other agent is unavailable to act. Your back-up agent should also
be over 18 and aware of your preferences.
You may revoke this document at any time while you are still competent to do so. You
may revoke it by telling your medical provider and your agent that you are revoking the
document or you may provide them a written revocation. If you execute another power
of attorney later, that will have the effect of revoking this one.
In order for this document to be valid, it must be signed in the presence of a notary or
two witnesses. If you choose to have two witnesses sign, they must be at least 18,
competent and independent and not your agent or related to your agent.
PowerofAttorney.com
Page 2 of 5
MEDICAL POWER OF ATTORNEY
I. APPOINTMENT OF HEALTH CARE AGENT
I, _______________________________ (Principal’s Full Name) of
_____________________________ (Principal’s Street Address), City of
_____________________________, State of _________________
(HEREINAFTER known as the “Principal”) hereby appoint,
_______________________________ (Agent’s Full Name) of
_____________________________ (Agent’s Street Address), City of
_____________________________, State of _________________
(HEREINAFTER known as the “Agent”)as my Agent to make any and all medical
decisions on my behalf, except to the extent I limit those decisions in this
document. This power of attorney takes effect if my doctor certifies in writing that
I can no longer make my own health care decisions. My agent can be reached at
the following contact information:
Home Phone :____________________ Work Phone : ____________________
Cell Phone: ____________________ E-Mail: ____________________________
II. LIMITATIONS ON MY AGENT
My agent is authorized to make all medical decisions on my behalf EXCEPT for
the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
III. APPOINTMENT OF ALTERNATE AGENT
If my agent appointed above is unable or unwilling to serve as my agent, I
appoint the following person(s) to serve as agents in the order set forth below
with the authority to make health care decisions on my behalf as provided herein:
A. First Alternate Agent
Name: _____________________________________________________
Address: ___________________________________________________
Phone: _____________________________________________________
PowerofAttorney.com
Page 3 of 5
B. Second Alternate Agent
Name: _____________________________________________________
Address: ___________________________________________________
Phone: _____________________________________________________
IV. ORIGINAL AND COPIES OF THIS DOCUMENT
The original document is/will be filed in the following place:
________________________________________________________________
________________________________________________________________
________________________________________________________________
I have/will provided copies of my medical power of attorney to the following:
________________________________________________________________
________________________________________________________________
________________________________________________________________
V. DURATION
Unless stated otherwise herein, this document shall remain in effect until I revoke
it. I understand that I cannot revoke this document during the time I am
considered incompetent to make my own decisions.
(If applicable Initial and Check)
___________ ☐ (OPTIONAL) This power of attorney shall expire on ____ day
of _________________________, 20____.
VI. PRIOR MEDICAL POWER OF ATTORNEY
By signing this document, I hereby revoke any and all prior medical powers of
attorney that I may have executed.
PowerofAttorney.com
Page 4 of 5
VII. EXECUTION
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY. YOU MAY SIGN
IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY
PUBLIC
OR
YOU MAY SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT
WITNESSES NOT RELATED BY BLOOD OR MARRIAGE.)
SIGNATURES
I /We hereby execute this document on ____ day of _____________________, 20____
in the City of ________________________, State of _______________.
Principal’s Signature _____________________ Print Name ______________________
Agent’s Signature _____________________ Print Name ______________________
1
st
Alt. Agent’s Signature ____________________ Print Name ___________________
2
nd
Alt. Agent’s Signature ____________________ Print Name ___________________
NOTARY ACKNOWLEDGMENT
STATE OF __________________
__________________ County, ss.
On this ____ day of __________________, 20____, before me appeared
____________________, as Maker of this Medical Power of Attorney who proved to me
through government issued photo identification to be the above-named person, in my
presence executed foregoing instrument and acknowledged that (s)he executed the
same as his/her free act and deed.
_________________________________________
Notary Public
Print Name: _____________________
My commission expires: _____________________
PowerofAttorney.com
Page 5 of 5
WITNESS STATEMENT AND ACKNOWLEDGMENT:
I am not the person appointed as agent or successor agent in this medical power
of attorney. I am not related to the maker of this document by blood or marriage. I
am not entitled to any portion of the maker's estate, nor do I have any claim
against the maker’s estate. I am not the attending physician of the maker or an
employee of the attending physician. I am not involved in providing direct patient
care to the maker and am not an officer, director, partner, or business office
employee of the health care facility or of any parent organization of the health
care facility.
SIGNATURE OF FIRST WITNESS
Signature: ________________________________________________
Print Name: ___________________________________ Date: __________
Address: __________________________________________________
SIGNATURE OF SECOND WITNESS
Signature: ________________________________________________
Print Name: ___________________________________ Date: __________
Address: __________________________________________________
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MEDICAL POWER OF ATTORNEY

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Completed 23 June 2021

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