MEDICAL POWER OF ATTORNEY

IMPORTANT INFORMATION

IT IS IMPORTANT THAT YOU REVIEW THE FOLLOWING INFORMATION BEFORE

YOU SIGN THIS DOCUMENT. READ THE INFORMATION CAREFULLY AND SEEK
GUIDANCE FROM A HEALTHCARE PROFESSIONAL OR ATTORNEY IF YOU DO
NOT UNDERSTAND ANY OF THE TERMS.

By signing this document, you are giving authority to the person you are designating as
your agent to make medical decisions on your behalf. Medical decisions can include
any medical service, treatment, medical procedure, diagnosis or treat both mental and
physical conditions. Your agent will be able to act with the same authority you would
have if you were able to act for yourself and will have the authority to consent, refuse to
consent to medical treatment including decisions about withdrawing or withholding life-
sustaining treatment. It is, therefore, important that you know and trust your agent and
that your agent is aware of your preferences for health care treatment.

Even after you sign this document, you will still be able to make your health care
decisions assuming you are still considered mentally competent. Your agent cannot act
on your behalf until your physician has determined that you are no longer physically or
mentally able to make medical decisions.

The person you choose as your agent must be at least eighteen years old and someone
that you trust with your health care. Your agent is not liable for any decisions they make
on your behalf, as long as those decisions were made in good faith. You should make
sure that you have chosen agent wants to take on the role as agent. Discuss your
medical preferences with your agent so they are aware of your wishes. Review this
document with your agent so they are aware of their role. You also may choose a back-
up agent in case your other agent is unavailable to act. Your back-up agent should also
be over 18 and aware of your preferences.

You may revoke this document at any time while you are still competent to do so. You
may revoke it by telling your medical provider and your agent that you are revoking the
document or you may provide them a written revocation. If you execute another power
of attorney later, that will have the effect of revoking this one.

In order for this document to be valid, it must be signed in the presence of a notary or
two witnesses. If you choose to have two witnesses sign, they must be at least 18,
competent and independent and not your agent or related to your agent.

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 MEDICAL POWER OF ATTORNEY

I. APPOINTMENT OF HEALTH CARE AGENT

Principal: I, ____________________, with a mailing address of

________________________________________, LEGALLY APPOINT

Agent: ____________________, with a mailing address of

________________________________________, as my Agent to make medical
decisions on my behalf, except to the extent I limit those decisions in this
document. This power of attorney takes effect with my signature and when my
doctor certifies in writing that I can no longer make health care decisions.

The Agent can be reached at the following contact details:

• Phone: ____________________
• E-Mail: ____________________________

II. LIMITATIONS ON MY AGENT

My agent is authorized to make all medical decisions on my behalf EXCEPT:

III. APPOINTMENT OF ALTERNATE AGENT

If my agent appointed above is unable or unwilling to serve as my agent, I

appoint the following person(s) to serve as agents in the order set forth below
with the authority to make health care decisions on my behalf as provided herein:

A. First Alternate Agent

Name: _____________________________________________________
Address: ___________________________________________________
Phone: _____________________________________________________

B. Second Alternate Agent

Name: _____________________________________________________
Address: ___________________________________________________
Phone: _____________________________________________________

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IV. ORIGINAL AND COPIES OF THIS DOCUMENT

The original document is/will be filed at the following location(s):

I have/will provide copies of my medical power of attorney to the following:

V. DURATION

Unless stated otherwise herein, this document shall remain in effect until I revoke
it. I understand that I cannot revoke this document during the time I am
considered incompetent to make my own decisions.

This power of attorney shall continue: (check one)

☐ - IN PERPETUITY. This power of attorney shall expire upon my death

or written revocation.

☐ - END DATE. This power of attorney shall expire on

____________________, 20____.

VI. PRIOR MEDICAL POWER OF ATTORNEY

By signing this document, I hereby revoke any and all prior medical powers of
attorney that I may have executed.

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VII. LEGAL REQUIREMENTS (STATE LAW)

YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY. YOU MAY SIGN
AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY
PUBLIC:

AND / OR

SIGN IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES NOT

RELATED BY BLOOD OR MARRIAGE.

VIII. EXECUTION

Principal’s Signature: ____________________________________

Print Name: __________________ Date: __________________

NOTARY ACKNOWLEDGMENT

A notary public or other officer completing this certificate verifies only the identity of
the individual who signed the document to which this certificate is attached, and not
the truthfulness, accuracy, or validity of that document.

State of: __________________}

County of: __________________}

On this ____ day of __________________, 20____, before me appeared

____________________, as Principal of this Medical Power of Attorney who
proved to me through government issued photo identification to be the above-
named person, in my presence executed foregoing instrument and
acknowledged that (s)he executed the same as his/her free act and deed.

Notary Public: ____________________________________

Print Name: __________________
My commission expires: __________________

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WITNESS STATEMENT AND ACKNOWLEDGMENT:

I am not the person appointed as agent or successor agent in this medical power
of attorney. I am not related to the principal of this document by blood or
marriage. I am not entitled to any portion of the principal’s estate, nor do I have
any claim against the principal’s estate. I am not the attending physician of the
principal or an employee of the attending physician. I am not involved in
providing direct patient care to the principal and am not an officer, director,
partner, or business office employee of the health care facility or of any parent
organization of the health care facility.

SIGNATURE OF FIRST WITNESS:

1st Witness Signature: ____________________________________

Print Name: __________________ Date: __________________
Address: ____________________________________

SIGNATURE OF SECOND WITNESS:

2nd Witness Signature: ____________________________________

Print Name: __________________ Date: __________________
Address: ____________________________________

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