North Carolina Statutory Form Health Care Power Of Attorney
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11Topic 3: Health Care Power of Attorney
Exhibit C: Health Care Power of Attorney
North Carolina Statutory Form Health Care Power of Attorney
(Notice: This document gives the person you designate your health care agent broad
powers to make health care decisions, including mental health treatment decisions, for you.
Except to the extent that you express specific limitations or restrictions on the authority of
your health care agent, this power includes the power to consent to your doctor not giving
treatment or stopping treatment necessary to keep you alive, admit you to a facility, and
administer certain treatments and medications.
This power exists only as to those health care decisions for which you are unable to give
informed consent.
This form does not impose a duty on your health care agent to exercise granted powers, but
when a power is exercised, your health care agent will have to use due care to act in your
best interests and in accordance with this document. For mental health treatment decisions,
your health care agent will act according to how the health care agent believes you would
act if you were making the decision. Because the powers granted by this document are
broad and sweeping, you should discuss your wishes concerning life-sustaining procedures,
mental health treatment, and other health care decisions with your health care agent.
Use of this form in the creation of a health care power of attorney is lawful and is
authorized pursuant to North Carolina law. However, use of this form is an optional and
nonexclusive method for creating a health care power of attorney and North Carolina law
does not bar the use of any other or different form of power of attorney for health care that
meets the statutory requirements.)
1. Designation of health care agent.
I, ____________, being of sound mind, hereby appoint:
Name: ______________________________
Home Address: __________________________
Home Telephone Number ________Work Telephone Number________
as my health care attorney-in-fact (herein referred to as my "health care agent") to act for
me and in my name (in any way I could act in person) to make health care decisions for me
as authorized in this document.
If the person named as my health care agent is not reasonably available or is unable or
unwilling to act as my agent, then I appoint the following persons (each to act alone and
successively, in the order named), to serve in that capacity:
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