Medical Power of Attorney Forms By State
What is Medical Power of Attorney?
Medical power of attorney is a form that allows a person to handle someone else’s health care decisions in the chance that he or she may not be able to think for themselves. The representative may not choose any ‘end of life’ decisions unless the Principal specifically writes in that he or she would like that as an option. If the Principal is consciously able to think for themselves then the representative has no say in their treatment.
How to Get Medical Power of Attorney?
Step 1 - Download.
Step 2 - Fill it in with the Attorney in Fact (representative) present to make sure you are both in agreement to the terms and conditions.
Step 3 - Authorize the document in front of a Notary Public. You can usually find one at every branch bank in the United States or you can go to 123notary.com and find a qualified person in your area.
The form may only be cancelled if the Principal signs a new power of attorney document or authorizes a cancellation (revocation).
Sample Medical Power of Attorney
1. Health Care Power of Attorney
I, ___________________________________, as principal, designate ______________________ as my agent for all matters relating to my health care, including, without limitation, full power to give or refuse consent to all medical, surgical, hospital and related health care. This power of attorney is effective on my inability to make or communicate health care decisions. All of my agent’s actions under this power during any period when I am unable to make or communicate health care decisions or when there is uncertainty whether I am dead or alive have the same effect on my heirs, devisees and personal representatives as if I were alive, competent and acting for myself.
If my agent is unwilling or unable to serve or continue to serve, I hereby appoint ____________________ as my agent.
I have _____ I have not _____ completed and attached a living will for purposes of providing specific direction to my agent in situations that may occur during any period when I am unable to make or communicate health care decisions or after my death. My agent is directed to implement those choices I have initialed in the living will.
I have _____ I have not _____ completed a prehospital medical care directive.
Signature of Principal
Witness: _____________________ Date: _____________________
_______________________________ Time: _____________________
Address: _____________________ ____________________________
Address of Agent
Witness: _____________________ ____________________________
_______________________________ Telephone of Agent
(Note: This document may be notarized instead of being witnessed.)
2. Autopsy (under law an autopsy may be required)
If you wish to do so, reflect your desires below:
_______ 1. I do not consent to an autopsy.
_______ 2. I consent to an autopsy.
_______ 3. My agent may give consent to or refuse an autopsy.
3. Organ Donation (Optional)
(Under law, you may make a gift of all or part of your body to a bank or storage facility or a hospital, physician or medical or dental school for transplantation, therapy, medical or dental evaluation or research or for the advancement of medical or dental science. You may also authorize your agent to do so or a member of your family may make a gift unless you give them notice that you do not want a gift made. In the space below you may make a gift yourself or state that you do not want to make a gift. If you do not complete this section, your agent will have the authority to make a gift of a part of your body pursuant to law. Note: The donation elections you make in this health care power of attorney survive your death.)
If any of the statements below reflects your desire, initial on the line next to that statement. You do not have to initial any of the statements.
If you do not check any of the statements, your agent and your family will have the authority to make a gift of all or part of your body under law.
_______ I do not want to make an organ or tissue donation and I do not want my agent or family to do so.
_______ I have already signed a written agreement or donor card regarding organ and tissue donation with the following individual or institution: ___________________________________
_______ Pursuant to law, I hereby give, effective on my death:
[___] Any needed organ or parts.
[___] The following part or organs listed:
for (check one):
[___] Any legally authorized purpose.
[___] Transplant or therapeutic purposes only.
4. Physician Affidavit (Optional)
(Before initialing any choices above you may wish to ask questions of your physician regarding a particular treatment alternative. If you do speak with your physician it is a good idea to ask your physician to complete this affidavit and keep a copy for his file.)
I, Dr. ___________________________ have reviewed this guidance document and have discussed with _______________ any questions regarding the probable medical consequences of the treatment choices provided above. This discussion with the principal occurred on _________________. (date)
I have agreed to comply with the provisions of this directive.
Signature of Physician
5. ___ Living Will (Optional)
6. ___ Funeral and Burial Disposition (Optional)
My agent has authority to carry out all matters relating to my funeral and burial disposition wishes in accordance with this power of attorney, which is effective upon my death.
My wishes are reflected below:
_______ Upon my death, I direct my body to be buried. (as opposed to cremated)
_______ Upon my death, I direct my body to be buried in ___________________________________________________. (Optional directive)
_______ Upon my death, I direct my body to be cremated.
_______ Upon my death, I direct my body to be cremated, with my ashes to be_______________________________________. (Optional directive)
_______ My agent may make all funeral and burial disposition decisions. (Optional directive)