Free Printable Medical (Health Care) Power of Attorney Forms

Medical power of attorney allows a person to handle someone else’s health care decisions only 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.

Medical Power of Attorney Form – Adobe PDF

Medical Power of Attorney Forms By State

Table of Contents

 

What is Medical Power of Attorney?

Medical power of attorney is a designation that is given to a person that enables them to handle health care related-decisions on a patient’s behalf. The exact decision-making responsibilities depend on what the patient instructs in the document. If the patient, for example, only wants to give powers related to non-life-threatening medical conditions.

Durable (Financial) Power of Attorney – Often times a durable, or financial power of attorney, is authorized at the same time with the agent being the same for both.

How to Get Medical Power of Attorney

To get medical power of attorney, the principal will need to have an agent selected and sign the document within the requirements for the State. Afterward, the agent selected will be able to make health care decisions immediately after the principal is no longer able to make themselves.

Step 1 – Identify the Roles

The person giving powers is known as the principal and the person receiving powers is known as the agent or attorney in fact.

Therefore, it’s very important that the principal chooses someone that is close to them and would have their best interests in mind when making any type of decision. Especially if the agent is to have end-of-life decision-making powers.

It’s recommended to have family members or the beneficiary named in the principal’s last will and testament to having such powers.

Step 2 – How many Agents to Choose

The principal can select, depending on the State, up to two (2) or three (3) health care agents to act on their behalf. Due to medical emergencies being able to occur at any time, it’s important to name more than one (1) agent in the document.

In the chance one (1) agent is not able to act, the other will be able to stand in their place. In most States, the agent choosing together is not allowed. Only one (1) agent is considered the sole decision-maker.

Step 3 – List the Agent’s Powers

The principal can choose to limit the powers of the agent by only allowing them to make decisions in certain situations. For example, if the principal is getting surgery, the document can be limited to that one (1) occurrence.

Compensation ($) – The principal can include language in the form that allows the agent to be paid for their services. It’s common for the principal to offer reimbursement for food, travel, and lodging while performing on their duties.

Step 4 – Signing the Form

The signing requirements depend on county and State where the form is being signed. It’s recommended to use the official version for the State the principal is a resident. In all States, there is the requirement of the form to be authorized in the presence of witnesses, a notary public, or both.

  • AL – Two (2) Witnesses
  • AK – Two (2) Witnesses or a Notary
  • AZ – One (1) Witness or a Notary
  • AR – Two (2) Witnesses or a Notary
  • CA – Two (2) Witnesses or a Notary
  • CO – Notarization recommended
  • CT – Two (2) Witnesses
  • DE – Two (2) Witnesses
  • FL – Two (2) Witnesses
  • GA – Two (2) Witnesses
  • HI – Two (2) Witnesses and a Notary
  • ID – Principal
  • IL – One (1) Witness
  • IN – One (1) Witness
  • IA – Two (2) Witnesses and a Notary
  • KS – Two (2) Witnesses or a Notary
  • KY – Two (2) Witnesses and a Notary
  • LA – Two (2) Witnesses
  • ME – Two (2) Witnesses
  • MD – Two (2) Witnesses
  • MA – Two (2) Witnesses
  • MI – Two (2) Witnesses
  • MN – One (1) Witness or a Notary
  • MS – Two (2) Witnesses or a Notary
  • MO – Notary Public
  • MT – Two (2) Witnesses
  • NE – Two (2) Witnesses and a Notary
  • NV – Two (2) Witnesses or a Notary
  • NH – Two (2) Witnesses or a Notary
  • NJ – Two (2) Witnesses or a Notary
  • NM – Notarization recommended
  • NY – Two (2) Witnesses
  • NC – Two (2) Witnesses and a Notary
  • ND – Two (2) Witnesses or a Notary
  • OH – Two (2) Witnesses
  • OK – Two (2) Witnesses
  • OR – Two (2) Witnesses
  • PA – Two (2) Witnesses
  • RI – Two (2) Witnesses or a Notary
  • SC – Two (2) Witnesses and a Notary
  • SD – Two (2) Witnesses or a Notary
  • TN – Two (2) Witnesses or a Notary
  • TX – Two (2) Witnesses or a Notary
  • UT – One (1) Witness
  • VT – Two (2) Witnesses
  • VA – Two (2) Witnesses
  • WA – Two (2) Witnesses or a Notary
  • WV – Two (2) Witnesses and a Notary
  • WI – Two (2) Witnesses
  • WY – Two (2) Witnesses or a Notary

Step 5 – Using the Form

Whenever the agent performs their duties under the medical power of attorney they will be required to carry a signed copy or original. By law, medical staff will request for the document to be shown.

Official “Name” of the Form: By State

The name of the form varies from State-to-State. Occasionally, medical power of attorney is combined with a living will and into an ‘Advance Directive‘.

  • AL – Advance Directive
  • AK – Advance Health Care Directive
  • AZ – Health Care Power of Attorney
  • AR – Durable Power of Attorney for Health Care
  • CA – Advance Health Care Directive
  • CO – Durable Power of Attorney for Healthcare Decisions
  • CT – Advance Directive
  • DE – Advance Health Care Directive
  • FL – Designation of Health Care Surrogate
  • GA – Advance Directive for Health Care
  • HI – Advance Health Care Directive
  • ID – Living Will and Durable Power of Attorney
  • IL – Power of Attorney for Health Care
  • IN – Health Care Power of Attorney
  • IA – Durable Power of Attorney for Health Care Decisions
  • KS – Durable Power of Attorney for Health Care
  • KY – Living Will Directive and Health Care Surrogate Designation
  • LA – Advance Directive
  • ME – Health Care Advance Directive Form
  • MD – Advance Directive
  • MA – Health Care Proxy
  • MI – Durable Power of Attorney for Health Care
  • MN – Health Care Directive
  • MS – Advance Health-Care Directive
  • MO – Durable Power of Attorney for Health Care
  • MT – Durable Power of Attorney for Health Care
  • NE – Power of Attorney for Health Care
  • NV – Durable Power of Attorney for Health Care Decisions
  • NH – Advance Directive
  • NJ – Durable Power of Attorney for Health Care
  • NM – Power of Attorney for Health Care
  • NY – Health Care Proxy
  • NC – Health Care Power of Attorney
  • ND – Health Care Directive
  • OH – Durable Power of Attorney for Health Care
  • OK – Durable Power of Attorney
  • OR – Advance Directive
  • PA – Durable Health Care Power of Attorney
  • RI – Designation of Health Care Agent
  • SC – Health Care Power of Attorney
  • SD – Durable Power of Attorney for Health Care
  • TN – Durable Power of Attorney for Health Care
  • TX – Medical Power of Attorney
  • UT – Advance Health Care Directive
  • VT – Durable Power of Attorney for Health Care
  • VA – Advance Directive for Health Care
  • WA – Durable Power of Attorney for Health Care
  • WV – Medical Power of Attorney
  • WI – Power of Attorney for Health Care
  • WY – Medical Power of Attorney

Medical Power of Attorney Laws: By State

Sample Medical Power of Attorney

Download (PDF, 143KB)

Medical Power of Attorney: How to Write

Download: Adobe PDF

1 – You Can Designate A Patient Advocate Utilizing The Template Previewed Here

If you have determined who your Patient Advocate should be and have decided what initiatives he or she should be able to engage in on your behalf, then locate the “PDF” button or “Adobe PDF” link above to download a copy of the template required. This can be saved to your computer and printed immediately if you access this file with your browser. Ideally, you will have a pdf editor that will enable you to prepare this paperwork for signing by entering information directly onscreen.

2 – Your Declaration Statement Must Introduce This Paperwork

When you are ready to prepare this appointment with information, locate the first blank space (labeled) “Name.” This empty space requires your full name placed on it. The first part of this statement will also require a report on the city and state where you live. The next two blank lines will give you a place where you may document first the city where you live, then the state where you live. The purpose for issuing this document will be to appoint a specific individual with the authority to represent you when you are a Patient who has been diagnosed as being unable to communicate with others or unconscious for a significant or extended period of time. This individual will be referred to as the Patient Advocate in that he or she will be called upon to make decisions on your behalf regarding your medical treatment and health care. To this end present the full name of your Patient Advocate on the empty line after the words “…Hereby Appoint” This declaration also needs your Patient Advocate’s full residential address entered on the blank space following the phrase “…Residing At” Keep in mind this should be a physical address, thus the Patient Advocate’s building number, street name, apartment number, city, state, and zip code should be produced on this line. If you foresee the potential scenario where medical decisions concerning your health need to be made but you are unconscious, and your Patient Advocate is unavailable then you may wish to name a backup agent. Such an entity would be able to assume the principal authority you are giving the Patient Advocate but only when the original agent cannot or will not represent you. This entity is referred to as a Successor Patient Advocate since he or she will inherit the ability to represent you in a successive manner. While not required, setting such an entity in place is popularly considered a wise precaution. The name of this entity should be placed on the line labeled “Successor Patient Advocate”  Place the Successor Patient Advocate’s residential address on the blank line labeled “Patient Advocate (Successor Patient Address).”

 

3 – Review The Actions Your Agent Will Be Authorized TO Take On Your Behalf

The next area that will require your attention consists of a lettered list. Each list item in this area gives a description of what your Patient Advocate can do in your name. You will need to read through each item then decide upon whether you wish the Patient Advocate to behave in such a manner. You may remove any of these items by deleting them or if you are working with this paperwork manually, you may strike through a list item and initial the crossed-out item. In fact, if you are preparing this paperwork manually, you must cross out each item. In the example below, the Patient Advocate will be able to conduct all the actions listed on your behalf except making any “Decision That Could Or Would Allow” your death. Notice that the entire list except for list item “E” which is crossed out then initialed by the Principal named on the first blank line.

 

4 – The Option To Give A Clear Description Of Your Wishes Is Included

The blank area under the statement “My Wishes Concerning Care As Follows.” This area provides a distinct area where you can set your directives on paper thus, solidifying what your preference in medical treatment(s) are and which treatments you wish barred from use. You may enter this information directly on these lines or, if you require additional space and are working with pen and paper, cite an attachment with your principal directives that you expect both Patient Advocate(s) and treating physicians to respect.

 

5 – Present The State Jurisdiction(s) Relevant To this Paperwork

The remainder of this document will serve to supplement your directives with the language required to solidify its purpose. The wording provided should not be altered unless it is by an attorney in the state where this document applies. One sentence in this section will require your input to be completed. In the statement beginning with the term “This Document Is Signed In The State Of,” enter the state where you will be physically executing this paperwork on the blank space provided.  List the state where you intend (and/or prefer) for this document to be presented and used by your Patient Advocate on the second blank space in this document.

6 – The Document Signing Is A Requirement Of The Execution Process

Make sure this document matches your intentions with no exceptions. You may revoke it at any time in the future however unless this happens the Patient Advocate(s) authorized to represent you will be sought out by medical professionals for direction when you are incapacitated and unable to communicate for yourself. You will execute this document to being active by signing your name on the blank space labeled “Signature” near the bottom of the second page. Immediately after signing your name, enter the current date next to it on the same line. Naturally, you will want anyone who comes in contact with this document to be able to contact you immediately. Fill in your telephone number(s) on the line labeled “Contact Number.” Then, turn this paperwork over to the two Witnesses watching you. The two Witnesses present must present his or her printed name and address then sign this document in the area provided under the heading “Names And Addresses Of Witnesses.” Note that each Witness must be cognizant, sober, and able to supply these items of his or own free will. When this task is completed, the Witnesses will give this document to the Notary Public.

The Notary Public will verify the authenticity of this signing by recording its location, your name, and his or her credentials.