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:
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:
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:
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:
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.
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 - __________________________
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:
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