Standard Medical Power of Attorney Templates - Legal

Medical Power of Attorney
State of
Date:
1. Appointment of a Health Care Agent

I, ________________________, the Principal, living at the primary Address of
________________________________________________________________________, City of
________________________, State of ________________________, hereby appoint,
________________________, the Agent, living at the primary Address of
________________________________________________________________________, City of
________________________, State of ________________________ as my Agent to act as set
forth below, in my name to make any and all medical decisions on my behalf unless I limit those
decisions in this document. This Medical Power of Attorney takes effect only when my Doctor
certifies in writing that I can no longer make my own health care decisions. My Agent can be
contacted on the following:
Mobile Number: ________________________
Home Phone Number: ________________________
Email: ________________________
Address: ___________________________________________________________________
2. My Agent’s Powers
My Agent understands my wishes from conversations and any other guidance I may have
written and signed. My Agent has complete authority to make decision on my behalf in regard
to my health care according to my wishes. If my wishes are unclear, then I grant my Agent
power to decide what they believe to be in my best interests. My Agent’s power is to be
interpreted from my wishes as broadly as possible and includes the following authority which I
have designated with my initials (This is only to be applicable if initialed).
(a) ____-To refuse, agree or withdraw consent to any type of medical care, surgical
procedures, treatment, medications or tests. This includes decisions in regard to any
procedure that affects my bodily functions such as artificial respiration, hydration,
artificial respiration, cardiopulmonary resuscitation, and any other form of medical
support, even if the refusal or withdrawal of treatment could or would result in my
death.
(b) ____-To have access to all my medical records and information to the same extent as I
am entitled to, including the right to disclose health information to others.
(c) ____-To hire and fire any medical, social service, and other support personnel who are
responsible for my care.
(d) ____-To refuse or to agree to using any medication or procedure intended to relieve
pain or discomfort, even though that use may lead to physical damage or dependence
or accelerate (unintentionally) my death.
(e) ____-To contract for any health care-related service or facility for me, or apply for
private or public health care benefits, with the understanding that my agent is not
personally financially responsible for those contracts.
(f) ____-To authorize my admission to or discharge from any hospital, nursing home,
residential care, assisted-living or similar facility or service.
(g) ____-To decide about organ and tissue donations, autopsy, and the disposition of my
remains as the law permits.
(h) ____-To authorize my participation in medical research related to my medical condition.
(i) ____-To take any other action necessary to do what I authorize here, including signing
waivers or other documents, pursuing any dispute resolution process, or taking legal
action in my name.
3. Special Instructions and Limitations for My Agent
4. Alternative Agents
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 out below with the authority to make
health care decision on my behalf as provided herein:
4.1. First Alternate Agent
Name: _______________________
Phone: _______________________
Address:_______________________________________________________________
4.2. Second Alternate Agent
Name: _______________________
Phone: _______________________
Address:_______________________________________________________________
5. Original and Copies of This Document
The original document will be filed
________________________________________________________________________
A copy of this document will be filed
6. Duration
Unless stated otherwise, this Medical Power of Attorney 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.
(This is only to be applicable if initialed).
____-This Medical Power of Attorney shall expire on _____ day of ______________, 20__.
7. Notary Public
NOTARY ACKNOWLEDGMENT
State of ________________________, ________________________ County, ss. On this _____

day of ______________, 20__, the foregoing document was acknowledged by
________________________, as Maker of this Medical Power of Attorney who proved they are
the above-named person through government issued photo identification, and in my presence
(s)he executed the foregoing instrument and acknowledged that (s)he executed the same as
his/her free act and deed.
________________________
Notary Public
________________________
Print Name
Commission Expiry Date: ________________________

8. Witnesses
Witness Statement and Acknowledgment
I am not related to the Maker of this document by blood or marriage. I am not the person
appointed as the Agent or Successor Agent in this Medical Power of Attorney. I am not involved
in providing direct patient care to the Maker and I 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. I do not have any claims against the Maker’s estate, nor am I entitled to any
portion of the Maker’s estate. I am not the attending physician of the Maker or an employee of
the attending physician.
8.1. Signature of the first witness
________________________
SIGNATURE
________________________
PRINT NAME
DATE: ________________________
ADDRESS:___________________________________________________________
8.2. Signature of the second witness
________________________
SIGNATURE
________________________
PRINT NAME
DATE: ________________________
ADDRESS: __________________________________________________________

Standard Medical Power of Attorney Templates - Legal

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Standard Medical Power of Attorney Templates - Legal

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Medical Power of Attorney

1. Appointment of a Health Care Agent

3. Special Instructions and Limitations for My Agent

If my Agent appointed above is unable or unwilling to serve as my Agent, I appoint the

4.1. First Alternate Agent

4.2. Second Alternate Agent

The original document will be filed

A copy of this document will be filed

(This is only to be applicable if initialed).

State of ____, County, ss. On this _

Commission Expiry Date: ________________________

Witness Statement and Acknowledgment

8.1. Signature of the first witness

8.2. Signature of the second witness

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