Medical Power of Attorney

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A Medical Power of Attorney is a legal document that appoints a trusted person to make healthcare decisions on your behalf when you become unable to make or communicate those decisions yourself.

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MEDICAL POWER OF ATTORNEY

This Medical Power of Attorney (hereinafter referred to as the "Document") is made and executed on .

DESIGNATION OF HEALTH CARE AGENT

I, , residing at , hereby appoint:

Name:
Address:
Phone:
Email:

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

ALTERNATE AGENTS

AGENT'S AUTHORITY

My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here: 

WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE

AGENT'S OBLIGATIONS

My agent shall make health care decisions for me in accordance with this power of attorney, any instructions I give in this document, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

NOMINATION OF GUARDIAN

If a guardian of my person needs to be appointed for me by a court, I nominate my agent (or alternate) named above for appointment as guardian to serve without bond or security.

HIPAA RELEASE AUTHORITY

I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160-164, and the regulations promulgated thereunder. I authorize any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered healthcare provider, any insurance company, and the Medical Information Bureau, Inc., or other healthcare clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose, and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present, or future medical or mental health condition.

SPECIFIC MEDICAL DIRECTIVES

ORGAN DONATION

Status:

Governing Law

This Medical Power of Attorney is governed by the state laws of .

EFFECT OF COPY

A copy of this Medical Power of Attorney has the same effect as the original.

SIGNATURE

I sign my name to this Medical Power of Attorney on .

Principal Signature: ______________________________
Print Name: _______________

ACCEPTANCE BY AGENT

I accept this appointment and agree to serve as agent for health care decisions. I understand I have a duty to act consistently with the principal's desires as stated in this document or otherwise made known to me. I understand that this document gives me authority to make health care decisions for the principal only if the principal becomes incapacitated. I understand that I must act in good faith in exercising my authority under this power of attorney. I understand that the principal may revoke this power of attorney at any time in any manner.

If I choose to withdraw as agent, I must inform the principal of my decision. If the principal is not capable of understanding my withdrawal, I must inform the principal's caregivers of my withdrawal.

Agent Signature: ______________________________
Print Name: _______________
Date:

What is a Medical Power of Attorney?

It designates a trusted individual to make healthcare decisions on your behalf when you cannot do so yourself. This document, sometimes called a healthcare proxy or healthcare surrogate, grants your chosen agent the authority to consult with your doctors, access your medical information, and make critical treatment decisions based on your previously expressed wishes. The appointed agent steps in when you become incapacitated due to illness, injury, or cognitive decline, ensuring your healthcare preferences are honored even when you cannot communicate them directly. Unlike a living will, which typically addresses end-of-life care specifically, a Medical Power of Attorney covers a broader range of healthcare decisions. It can be activated for temporary and permanent incapacity situations.

Key aspects and use cases:

  • Ensures your healthcare wishes are followed when you cannot express them;
  • Provides clear authority for a trusted person to make medical decisions;
  • Helps prevent family conflicts about your medical care;
  • Valuable for surgical procedures with potential complications;
  • Essential for those with progressive conditions like dementia;
  • Can be tailored to grant limited or comprehensive decision-making power;
  • Most effective when combined with advance directives detailing your preferences.

How to Get a Medical Power of Attorney

Establishing a medical power of attorney is an important step in ensuring your healthcare decisions are honored, even if you’re unable to communicate them yourself. This process involves choosing the right person to act as your agent and clearly defining the extent of their authority.

1. Selecting an Agent

The most crucial part of creating a medical power of attorney is selecting someone you trust. This person should understand your values, be capable of advocating for your wishes under pressure, and remain emotionally grounded in difficult situations.

Ideally, your agent should live nearby so they can be present quickly in emergencies. Before finalizing your choice, have an open conversation with the person to ensure they're willing to take on the responsibility. It's also wise to name at least one alternate agent in case your primary choice is unavailable when needed.

2. Determining Scope of Authority

Your agent’s authority should reflect your preferences on critical medical decisions. You’ll need to decide whether they can approve or deny interventions such as:

  • Mechanical ventilation
  • Cardiopulmonary resuscitation (CPR)
  • Artificial nutrition and hydration
  • Dialysis

Beyond life-sustaining treatments, think about:

  • Palliative care: Make your wishes clear regarding comfort measures and pain management.
  • Experimental treatments: Decide if your agent can authorize participation in clinical trials.
  • Mental health: Consider whether they should make decisions about psychiatric care, such as medication or hospitalization.
  • Organ and tissue donation: Specify if and how you'd like to donate for transplant or research purposes.

3. Documentation Requirements

Medical power of attorney forms vary by state, but you can typically obtain them from hospitals, your doctor’s office, or your state health department’s website.

When filling out the form, be thorough—provide accurate details about yourself and your designated agent(s). Most jurisdictions require the document to be signed in front of two adult witnesses who:

  • Are not related to you
  • Will not benefit from your estate

Although not always required, notarizing the document can add an extra layer of legal validity. Be sure to review and update the form after significant life events or health changes.

4. Distributing the Document

Once completed, distribute copies to everyone who may need access in a medical emergency. This includes:

  • Your primary and alternate agents
  • Your doctor and healthcare providers
  • The hospital's medical records department
  • Trusted family members

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Comments and opinions expressed by users on this website are for informational purposes only and do not constitute legal advice. They reflect the personal views of the commenters and should not be relied upon as a substitute for professional legal counsel. Always consult a qualified attorney for advice specific to your situation.

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