A medical power of attorney allows a person (principal) to designate an agent to handle health care decisions on their behalf. In most cases, this form only becomes effective when patients cannot speak for themselves.

This is common for the elderly or those who cannot respond to medical staff and direct them to their preferences for health care.

By State

1. Choose an Agent

The principal, who is making the power of attorney, needs to choose someone they can trust to be their agent. The agent’s responsibilities will be to make any and all health care related decisions in the event the principal cannot speak for themselves.

The agent must be available at a moment’s notice to be, in-person, to act on behalf of the principal.

2. Appoint Alternate Agents

Agents cannot work together as co-agents. Although, the principal can choose secondary agents in the event the 1st agent is not able to perform their duties.

Up to 2 alternate agents may be entered into the power of attorney (making 3 agents total).

3. Select Powers / Exceptions

The principal must select the powers the agents will have. By default, the agents will be able to make any decision legal under state law unless there are specific exceptions written by the principal.

4. Duration

Enter how long the power of attorney will be in effect. For example, if the principal is undergoing a one-time procedure, they may choose to have the document end on a specific date.

If the principal wants to have the power of attorney for a long term, no date should be entered into the document.

5. Sign

The principal will be required to sign the power of attorney in accordance with state law. This requires the principal to sign in the presence of a notary public, two (2) disinterested witnesses, or both.

Once the power of attorney is signed, it may be used by the agent by simply presenting it to medical staff.

A medical power of attorney is not filed with any recording office or government agency.

Sample

MEDICAL POWER OF ATTORNEY FORM

I. THE PARTIES. My name is [PRINCIPAL’S NAME] with a mailing address of [PRINCIPAL’S ADDRESS] (“Principal”) and hereby appoint:

Agent’s Name: [NAME]
Agent’s Address: [ADDRESS]
Agent’s Phone: [PHONE]

I have selected the above-mentioned agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. This medical power of attorney takes effect if I cannot make my own health care decisions, and this fact is certified in writing by my physician.

II. LIMITATIONS. My agent’s limitations on decision-making are as follows: [DESCRIBE ANY LIMITATIONS]

III. ALTERNATE AGENT(S) (OPTIONAL). If the person designated as my agent is unable or unwilling to make health care decisions for me, I designate the following person(s) to serve as my agent to make health care decisions for me as authorized by this document, who serve in the following order:

Alternate Agent

1^st Alternate Agent’s Name: [NAME]
1^st Alternate Agent’s Address: [ADDRESS]
1^st Alternate Agent’s Phone: [PHONE]

IV. PRIOR DESIGNATIONS. I revoke any prior medical power of attorney documents made or any documents created where a health care proxy was appointed.

V. DISCLOSURE STATEMENT. THIS MEDICAL POWER OF ATTORNEY IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are unable to make the decisions for yourself. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. Your agent may not consent to voluntary inpatient mental health services, convulsive treatment, psychosurgery, or abortion. A physician must comply with your agent’s instructions or allow you to be transferred to another physician.

Your agent’s authority is effective when your doctor certifies that you lack the competence to make health care decisions. Your agent is obligated to follow your instructions when making decisions on your behalf.

The person you appoint as agent should be someone you know and trust. The person must be 18 years of age or older or a person under 18 years of age who has had the disabilities of a minority removed. If you appoint your health or residential care provider (e.g., your physician or an employee of a home health agency, hospital, nursing facility, or residential care facility, other than a relative), that person has to choose between acting as your agent or as your health or residential care provider; the law does not allow a person to serve as both at the same time.

THIS POWER OF ATTORNEY IS NOT VALID UNLESS:

YOU SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC; OR
YOU SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES.

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY. YOU MAY SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE (1) A NOTARY PUBLIC OR YOU MAY SIGN IT IN THE PRESENCE OF (2) TWO COMPETENT ADULT WITNESSES.)

Principal’s Signature: _____________________ Date: [DAY] day of [MONTH], 20[XX]
Print Name: _____________________________
Address: ________________________________

STATEMENT OF WITNESSES.

We, the witnesses hereunder mentioned, am appointed as an agent by this document.

Witness’s Signature: _____________________ Date: [DAY] day of [MONTH], 20[XX]
Print Name:_____________________________
Address: _______________________________