FREE MEDICAL POWER OF ATTORNEY FORM
Special, Durable, General Template

A Medical Power of Attorney is also known as a power of attorney for health care or health care power of attorney. It is a legal document that enables someone to make decisions for you on healthcare matters.

How to Create a Medical Power of Attorney:

  • Search for POA templates online
  • By filling the form you should name One Agent, and if necessary an alternate, describing his or her powers and responsibilities
  • The names, addresses, and phone numbers
  • Start and End Dates
  • Have one or two witness
  • Sign the Form
  • Take it to a Notary and have it notarized
  • Distribute copies to the doctor, hospital or private care health clinics
  • Keep a copy for yourself
  • Update the form as necessary

There’s no need to use an attorney to create a Medical Power of Attorney. Although getting assistance from a lawyer it’s always a good idea if you have any doubt about this type of document.

Your designed agent then will be able to make decisions concerning:

  • Which physicians, hospitals or clinics to work with
  • The right to access medical records
  • What kinds of drug treatments should be carried out (if any)
  • The selection or discharge of any care provider or institution utilized in your care
  • What types of tests to run
  • Wheather or not to perform surgery
  • When to perfom surgery
  • How aggressively the disease or brain damage should be treated
  • Whether to disconnect life support in case of a coma
  • Wheather or not to do everything possible to extend life
  • The capability to authorize an autopsy
  • How the remains shoul be disposed

How to choose your agent:

The person you choose must be someone you trust enough to handle life-and-death matters  for you. Like your spouse, adult daughter or son, or longtime best friend. Make sure the person you pick:

  • Is a mentally competent adult
  • Has read and understands your living will
  • Understands the medical explanations described by your physician
  • Has discussed specific scenarios and your medical wishes with you
  • Is not your doctor or health care provider (this requirement holds in most states)

A medical POA is used to designate and authorizes someone you trust (known as agent, surrogate, health care proxy, or attorney-in-fact) to make medical decisions for your or your children. In case you will be leaving a child in someone else’s care for an extended period of time.

If the parents of a child are not married, most states require a parent to provide the other with written notice of the Medical Power of Attorney. Otherwise, both parents must sign the POA.

You need to create a separate power of attorney if you need someone else to make financial decisions on your behalf, a financial POA.

MEDICAL POWER OF ATTORNEY


BE IT KNOWN TO ALL, that I, ________________________, holder of identification  number ___________________, being of the age of consent of eighteen (18) years or older and currently residing at __________________________________________, in the County of ________________________ State of ________________________ zip code _________, do hereby designate, establish and appoint _________________________, holder of identification number _________________________, currently residing at _________________________________________________, in the County of _________________ State of ________________________ zip code _________,as my official allocated Attorney-in-Fact ("Agent") to perform in my name and stead as of ________________________. 

This medical power of attorney takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician.

MY AGENT’S POWERS SHALL INCLUDE THE AUTHORITY TO: 

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

The following are LIMITATIONS on the decision making authority of my agent:

__________________________________________________________

__________________________________________________________

__________________________________________________________

ALTERNATE AGENT:

I hereby designate ___________________________________, holder of identification number ________________, currently residing at ______________________________, in the County of _________________ State of ________________________ zip code _________ to serve as my agent to make health care decisions for me, if the above designated person as my agent is unwilling or unable to make healthcare decisions for me.

This Medical Power of Attorney, shall not be affected by subsequent incapacity of the Principal.

This Medical Power of Attorney shall be effective from the date of its execution and shall remain in force indefinitely unless revoked.

Dated ____/____/________.

Principal Signature - __________________________

By accepting this appointment and acting under it, I the AGENT ("attorney-in-fact") do hereby assume the legal responsibilities of an agent.

Agent Signature - __________________________

WITNESSES:

We, the undersigned witnesses, do hereby declare under penalty of perjury that we have witnessed the Principal whose name, identity and handwriting are known to us signing and executing this Medical Power of Attorney in our presence. Further we declare that we are not related to the Principal by blood nor by marriage nor by adoption nor are we involved in providing medical treatment to the Principal nor are we beneficiaries under the Principal’s Last Will and Testament and that the Principal appears, in our best judgement, to be acting in sound mind, voluntarily and free from external influences, stress, duress and undue influence.

Signature of Witness #1 - __________________________ ID# ________________

Signature of Witness #2 - __________________________ ID# ________________

This Medical Power of Attorney shall be governed by the laws of the State of ___________ in County of _____________________ and any applicable Federal Law.

The original of the document shall be kept at: _________________________________

The following individual or institution shall have signed copies of the document:

Name: _____________________________________

Address: ____________________________________________

NOTARY:

STATE OF ________________________,

COUNTY OF ________________________

On __________________ the aforementioned parties appeared before me, a Notary Public, for the above state and county, and is known to me or provided photo identification and that such individuals executed the foregoing instrument, and being duly sworn, such individuals acknowledged that s/he executed said instrument for the purpose therein contained of his/her free will and voluntary act.

(SIGNATURE NOTARY PUBLIC)

My Commission expires: ______________________________


New England Region: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

Great Lakes States: Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Middle Atlantic States: Delaware, New Jersey, New York, Pennsylvania

Atlantic Coast and Appalachian States: Kentucky, Maryland, North Carolina, Tennesse, Virginia, West Virginia

Southeast and Gulf States: Alabama, Florida, Georgia, Mississippi, South Carolina

Mountain States: Colorado, Idaho, Montana, Utah, Wyoming

Plains States: Iowa, Kansas, Missouri, Nebraska, North Dakota, South Dakota

South Central States: Arkansas, Lousiana, Oklahoma, Texas

Southwest Desert States: Arizona, Nevada, New Mexico

Pacific States: Alaska, California, Hawaii, Oregon, Washington


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