The Person I Want to Make Health Care Decisions

For Me When I Can’t Make Them for Myself

Dated: [DAY] day of [MONTH], 20[XX]

I,[NAME] (Insert your name), hereby appoint as my representative to act on my behalf to give, withhold, or withdraw informed consent to health care decisions in the event that I am unable to do so myself.

The person I choose as my representative is:

[NAME]
[ADDRESS, CITY, STATE, ZIP CODE]
[PHONE NUMBER]

This appointment shall extend to, but not be limited to, health care decisions relating to medical treatment, surgical treatment, nursing care, medication, hospitalization, care and treatment in a nursing home or other facility, and home health care. The representative appointed by this document is specifically authorized to be granted access to my medical records and other health information and to act on my behalf to consent to, refuse, or withdraw any and all medical treatment or diagnostic procedures, or autopsy if my representative determines that I, if able to do so, would consent to, refuse, or withdraw such treatment or procedures.

It is my intent that this document be legally binding and effective and that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period when I am unable to make such decisions.

SPECIAL DIRECTIVES OR LIMITATIONS ON THIS POWER: Comments about tube feedings, breathing machines, cardiopulmonary resuscitation, dialysis, mental health treatment, funeral arrangements, autopsy, and organ donation may be placed here. My failure to provide special directives or limitations does not mean I want or refuse certain treatments.

THIS MEDICAL POWER OF ATTORNEY SHALL BECOME EFFECTIVE ONLY UPON MY INCAPACITY TO GIVE, WITHHOLD, OR WITHDRAW INFORMED CONSENT TO MY OWN MEDICAL CARE.

______________________________
Signature of the Principal

[ADDRESS, CITY, STATE, ZIP CODE]
Address of Principal

I did not sign the principal’s signature above.  I am at least 18 years of age and am not related to the principal by blood or marriage. I am not entitled to any portion of the estate of the principal or to the best of my knowledge under any will of the principal or codicil thereto, nor legally responsible for the costs of the principal’s medical or other care. I am not the principal’s attending physician, nor am I the representative or successor representative of the principal.

_______________________________        [DAY] day of [MONTH], 20[XX]
Witness

_______________________________        [DAY] day of [MONTH], 20[XX]
Witness

STATE OF [STATE]
COUNTY OF [COUNTY]

I, [NAME], a Notary Public of said County, do certify that [NAME], as principal, and [NAME] and [NAME], as witnesses, whose names are signed to the writing above bearing date on the [DAY] day of [MONTH], 20[XX], have this day acknowledged the same before me.

Given under my hand this [DAY] day of [MONTH], 20[XX].
My commission expires: [DAY] day of [MONTH], 20[XX]