Medical Power Of Attorney Form printable pdf download

Medical Power of Attorney (pg 1 of 2)

Effective Upon Execution

I, [NAME]_________________________________, a resident of [ADDRESS, COUNTY,

[STATE]______________________________________________________________________________________;

Social Security Number [NUMBER_________________________ ; designate [NAME]________________________;

presently residing at [ADDRESS] _________________________________, [PHONE NUMBER]________________;

as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document.

For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of

consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental

condition. 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.

Limitations: [Describe any desired limitations, for example, concerning life support, life-prolonging care, treatment,

services, and procedures.]

_____________________________________________________________________________________________

Inspection and Disclosure of Information Relating to My Physical or Mental Health: Subject to any limitations in this

document, my agent has the power and authority to do all of the following:

Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but

not limited to, medical and hospital records;

Execute on my behalf any releases or other documents that may be required in order to obtain this information;

Consent to the disclosure of this information.

Additional Powers: Where necessary to implement the health care decisions that my agent is authorized by this

document to make, my agent has the power and authority to execute on my behalf all of the following:

Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice";

Any necessary waiver or release from liability required by a hospital or physician.

Duration: This power of attorney exists indefinitely from its date of execution, unless I establish herein a shorter time

or revoke the power of attorney.

[If applicable: This power of attorney expires on [DATE]_______________________. If I am unable to make health

care decisions for myself when this power of attorney expires, the authority I have granted my agent shall continue to

exist until such time as I become able to make health care decisions for myself.]

Alternative Agent: In the event that my designated agent becomes unable, unwilling, or ineligible to serve, I hereby

designate [NAME]___________________________________, presently residing at

[ADDRESS]__________________________________________________, [PHONE NUMBER]_________________

as my as my first alternate agent, and [NAME]_________________________________, presently residing at

[ADDRESS]__________________________________________________, [PHONE NUMBER]_________________

as my as my second alternate agent.

Prior Designations Revoked: I revoke any prior Medical Power of Attorney.

Location of Documents:

The original copy of this Medical Power of Attorney is located at:

[Location]_______________________________________________________________.

Signed copies of this Medical Power of Attorney have been filed with the following individuals and institutions:

[Names and Addresses]____________________________________________________________________.

I sign my name to this Medical Power of attorney on the date of [DATE]_______________, at [ADDRESS, COUNTY,

STATE]______________________________________________________________________________________

__________________________________________________________________

Signature

Medical Power Of Attorney Form

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