Fillable Medical Power Of Attorney Form printable pdf download

MEDICAL POWER OF ATTORNEY

I, _____________________________ (your name), of __________________________

(address) , appoint _______________________________, as my agent (attorney-in-fact) to

act for me in any lawful way with respect to, except as stated otherwise in any Directive to

Physicians, Advance Directive for Health Care, Living Will, or similar validly executed

document, and during any period in which I am incapacitated, give or withhold consent to any

medical, psychiatric or psychological procedures, tests or treatments, including surgery; to

arrange for my hospitalization, nursing home care, convalescent care, hospice or home care;

to summon paramedics or other emergency medical personnel and seek emergency

treatment for me, as my attorney-in-fact shall deem appropriate; and under circumstances in

which my attorney-in-fact determines that certain medical procedures, tests or treatments are

no longer of any benefit to me or where benefits are outweighed by the burdens imposed to

revoke, withdraw, modify or change consent to such procedures, tests and treatments, as well

as hospitalization, convalescent care, hospice or home care which I or my attorney-in-fact

may have previously allowed or consented to or which may have been implied due to

emergency conditions. My attorney-in-fact's decisions should be guided by taking into

account: 1) the provisions of this instrument; 2) any reliable evidence of preferences that I

may have expressed on the subject whether before or after the execution of this instrument;

3) what my attorney-in-fact believes I would want done in the circumstances if I were able to

express myself; 4) any information given to my attorney-in-fact by the physicians treating me

as to my medical diagnosis and prognosis and the intrusiveness, pain, risks and side effects

of the treatment; 5) views of other family members and trustee(s) of any trusts created by me

during my lifetime; and 6) any Directive to Physicians, Advance Directive for Health Care,

Living Will, or similar validly executed document.

_______________________________________________________

(Attach additional pages if needed.)

UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF ATTORNEY IS

EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED.

This power of attorney shall not be affected by subsequent disability or incapacity of the

principal, or lapse of time.

STRIKE THE PRECEDING SENTENCE IF YOU DO NOT WANT THIS POWER OF

ATTORNEY TO CONTINUE IF YOU BECOME DISABLED, INCAPACITATED, OR

INCOMPETENT.

I agree that any third party who receives a copy of this document may act under it.

Revocation of the power of attorney is not effective as to a third party until the third party

learns of the revocation. I agree to indemnify the third party for any claims that arise against

the third party because of reliance on this power of attorney.

Medical Power of Attorney : Page 1 of 2

Medical Power Of Attorney Form