Medical Power of Attorney
This Medical Power of Attorney is a legal document that grants the person you designate—the agent—the authority to make healthcare decisions on your behalf if you become unable to do so. This form is designed to comply with the laws of the specific state mentioned and should be filled out with the assistance of a legal advisor to ensure it meets your individual needs.
State-Specific Legislation: _________ [Insert State Name Here]
This document is pursuant to the provisions of the _________ [Insert Relevant State-Specific Legislation Here], which dictates the creation and use of a Medical Power of Attorney within the state.
Principal Information:
- Full Name: ___________ [Insert Full Name Here]
- Address: ___________ [Insert Address Here]
- Date of Birth: ___________ [Insert Date of Birth Here]
- Social Security Number: ___________ [Insert Social Security Number Here, if applicable]
Agent Information:
- Full Name: ___________ [Insert Full Name of Agent Here]
- Relationship to Principal: ___________ [Insert Relationship Here]
- Address: ___________ [Insert Address Here]
- Alternative Phone Number: ___________ [Insert Phone Number Here]
Alternate Agent Information (Optional):If the primary agent is unable or unwilling to serve, an alternate agent may act in their stead. This is optional but recommended.
- Full Name: ___________ [Insert Full Name of Alternate Agent Here]
- Relationship to Principal: ___________ [Insert Relationship Here]
- Address: ___________ [Insert Address Here]
- Alternative Phone Number: ___________ [Insert Phone Number Here]
Authority of Agent:
The agent is granted the authority to make any and all health care decisions on the principal's behalf that the principal could make if capable. This includes, but is not limited to, the authority to consent to give, withhold, or withdraw consent to medical treatment, including life-sustaining treatments and artificially provided food and water.
Directions Regarding Health Care:
Here, the principal may include specific limitations on the agent's authority, conditions, or directions regarding the health care decisions.
_________ [Insert Specific Instructions/Limitations Here]
Effective Date and Signatures:
This Medical Power of Attorney shall become effective on the date it is signed unless otherwise specified here: _________ [Insert Effective Date Here].
This document must be signed by the principal in the presence of a witness who is not the agent or relative of the principal. It may also require notarization depending on the state law.
_________________ [Principal's Signature]
_________________ [Date]
_________________ [Agent's Signature]
_________________ [Date]
Witness:
I, ___________ [Insert Witness Name Here], declare that the principal appears to be of sound mind and free of duress or undue influence and has affirmed to me that they are aware of the nature of this document and has signed it willingly and freely.
_________________ [Witness's Signature]
_________________ [Date]
Notarization (If applicable):
This section to be completed by a notary public if required by the laws of the state of _________ [Insert State Name Here].