This Medical Power of Attorney document designates an individual as the grantor's (the
person signing the document) health care agent. The health care agent has the power
to make medical and health care decisions for the grantor if the grantor's physician
certifies that the grantor is unable to make his or her own health care decisions. The
agreement provides certain limitations and has an indefinite time duration from
execution. A medical power of attorney is sometimes called a durable power of attorney
for health care. This document can be modified to best fit the needs of an individual
granting power of attorney for medical decisions.
MEDICAL POWER OF ATTORNEY
(Effective upon Execution)
Designation of Health Care Agent
I, ______________________, hereby appoint ___________ [Name], of _______________
[Address] _________________ [Phone Number] to serve as my agent 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 shall take effect without further action if I become unable to make my own
health care decisions and this fact is certified in writing by my physician.
The following limitations apply to this Medical Power of Attorney designation:
______________________________________________________________________________
_____________________________________________________________________________.
[Describe any desired limitations, for example, concerning life support, life-prolonging care,
treatment, services, and procedures]
Limitations
Subject to the limitations set forth above, my agent has the power and authority to do all of the
following:
1. Request, review, and receive any information, verbal or written, regarding my physical or
mental health, including, but not limited to, medical and hospital records;
2. Execute on my behalf any releases or other documents that may be required in order to
obtain this information;
3. Consent to the disclosure of this information.
Designation of Alternate Agent
If the person designated above as my agent is unable or unwilling to make health care decisions
for me, I designate the following person, to serve as my agent to make health care decisions for
me as authorized by this document, who serve shall in the following order:
Alternate Agent:
Name: ________________________________________________
Address: ______________________________________________
Phone: ________________________________________________
Duration
I understand that this Medical Power of Attorney exists indefinitely from the date I execute this
document unless I establish a shorter time or revoke the powers designated herein. If I am
unable to make health care decisions for myself when this Medical Power of Attorney expires,
the authority I have granted to my agent herein shall continue to exist until such time as I become
able to make health care decisions for myself.
© Copyright 2013 Docstoc Inc. registered document proprietary, copy not 2
Prior Designations Revoked
I revoke any other Medical Power of Attorney executed or contemplated prior to the date set
forth below.
Location of Documents
The original copy of this Medical Power of Attorney is located at _______________. Signed
copies of this Medical Power of Attorney have been given to the following individuals and filed
at the following institutions: ___________________________________________.
I hereby sign my name to this Medical Power of Attorney on the __________ day of
_______________, ___________ at _________________________ (City),
____________________________________ (State).
(Signature) ____________________________________________
(Print Name)___________________________________________
Witness
I am not the person appointed as agent in this document. I am not related to the principal by
blood or marriage. I would not be entitled to any portion of the principal’s estate on the
principal’s death. I am not the attending physician of the principal or an employee of the
attending physician. I have no claim against any portion of the principal’s estate upon the
principal’s death. Furthermore, if I am an employee of a health care facility in which the
principal is a patient, I am not involved in providing direct patient care to the principal and am
not an officer, director, shareholder, or partner of the health care facility or of any parent
organization of any health care facility providing same.
Signature First Witness: ____________________________________
Print Name: _____________________________________________
Date: ___________________________________________________
Address: ________________________________________________
Signature of Second Witness: ________________________________
Print Name: ____________________________________