Fillable Form Medical Power of Attorney

What is a Medical Power of Attorney?

A Medical Power of Attorney, or also referred to as Power of Attorney for My Health Care, is used by individuals to grant legal authorization for a designated person or agent to make decisions about their medical care and aspects of their health.

Any competent adult can be an agent, but some states enforce the following exclusions:

• A physician or health care provider
• An employee of an individual’s physician or health care provider
• A residential health care provider
• An employee of your residential health care provider

If an individual has any of the designations mentioned above, they cannot act as someone’s agent for the purposes of a medical power of attorney in some states.

How to fill out a Medical Power of Attorney?

Individuals can write their own Medical Power of Attorney Template or download a PDF copy from a website that offers document templates. For convenience, they can also fill out the Medical Power of Attorney Template electronically on PDFRun.

To fill out a Medical Power of Attorney Template, you must provide the following information:

Information About the Principal

Enter information about yourself.

Principal’s full name

Enter your full legal name.

Principal’s street address

Enter your street address.

City

Enter your city.

State

Enter your state.

ZIP code

Enter your ZIP code.

Principal’s daytime phone

Enter your daytime telephone number.

Principal’s other phone

Enter your other telephone number.

Principal’s birthday

Enter the date of your birth.

Principal’s email address

Enter your email address.

Who will be your health care agent?

Enter information about your primary health care agent.

Agent’s full name

Enter the full legal name of your agent.

Agent’s street address

Enter the street address of your agent.

City

Enter the city of your agent.

State

Enter the state of your agent.

ZIP code

Enter the ZIP code of your agent.

Agent’s daytime phone

Enter the daytime telephone number of your agent.

Agent’s other phone

Enter the other telephone number of your agent.

Agent’s birthday

Enter the date of birth of your agent.

Agent’s email address

Enter the email address of your agent.

Who will be your back-up agents?

Enter information about your back-up agent just in case your primary agent is unwilling or unable to act for any reason.

Back-up Agent’s full name

Enter the full legal name of your back-up agent.

Back-up Agent’s street address

Enter the street address of your back-up agent.

City

Enter the city of your back-up agent.

State

Enter the state of your back-up agent.

ZIP code

Enter the ZIP code of your back-up agent.

Back-up Agent’s daytime phone

Enter the daytime phone number of your back-up agent.

Back-up Agent’s other phone

Enter the other phone number of your back-up agent.

Back-up Agent’s birthday

Enter the date of birth of your back-up agent.

Back-up Agent’s email address

Enter the email address of your agent.

Second Back-up Agent’s full name

Enter the full legal name of your second back-up agent.

Second Back-up Agent’s street address

Enter the street address of your second back-up agent.

City

Enter the city of your second back-up agent.

State

Enter the state of your second back-up agent.

ZIP code

Enter the ZIP code of your second back-up agent.

Enter information about your second back-up agent just in case your first two agents are unwilling or unable to act for any reason.

Second Back-up Agent’s daytime phone

Enter the daytime telephone number of your second back-up agent.

Second Back-up Agent’s other phone

Enter the other telephone number of your second back-up agent.

Second Back-up Agent’s birthday

Enter the date of birth of your second back-up agent.

Second Back-up Agent’s email address

Enter the email address of your second back-up agent.

What will your agent’s powers be?

Your agent must know your goals and wishes based on your conversations and any other guidance you may have written. Your agent will have full authority to make decisions for you about your health care according to your goals and wishes. If the choice you are going to make happens to be unclear, then your agent will have the right to decide based on what he or she believes to be in your best possible interests.

Your agent’s authority to interpret your wishes is intended to be as broad as possible and must include the following authority of your choice. Mark the appropriate boxes which correspond to the powers you wish to grant your agent. You may select:

1. To agree to, refuse, or withdraw consent to any type of medical care, treatment, surgical procedures, tests, or medications.

a. Principal’s initials - Enter your initials.

2. To have access to medical records and information to the same extent that you are entitled to, including the right to disclose health information to others.

3. To authorize your admission to or discharge even against medical advice from any hospital, nursing home, residential care, assisted living, or similar facility or service.

4. To contract for any healthcare-related service or facility for you or apply for public or private health care benefits, with the understanding that your agent is not personally financially responsible for those contracts.

5. To hire and fire medical, social service, and other support personnel who are responsible for my care.

6. To authorize my participation in medical research related to my medical condition.

7. To agree to or refuse using any medication or procedure intended to relieve pain or discomfort, even though that use may lead to physical damage or dependence or hasten but not intentionally cause your death.

8. To decide about organ and tissue donations, autopsy, and the disposition of your remains as the law permits.

9. To take any other action necessary to do what you authorize here, including signing waivers or other documents, pursuing any dispute resolution process, or taking legal action in my name.

Do you have special instructions or limitations for your agent?

Effective power

This power of attorney for your health care will become effective during any time in which you are unable to make or communicate a choice about a certain health care decision in the opinion of your agent and attending physician.

Other provisions

You and your agent must follow the following provisions:

1. Health care providers can rely on your agent. No one who relies in good faith on any representations by your agent or back-up agent will be liable to you, your estate, your heirs or assigns for recognizing the agent’s authority.
2. You shall cancel any previous power of attorney for health care that you may have signed.
3. You intend to use this power of attorney universally. It shall be valid in any jurisdiction in which it is presented.
4. You shall state that the copies of these documents will be as effective as the original.
5. Your agent will not be entitled to compensation for services performed under this power of attorney, but he or she will be entitled to reimbursement for all reasonable expenses that have been made.

Signature

Principal’s signature

Affix your signature.

Principal’s name

Enter your full legal name.

Date

Enter the current date of signing.

A statement by your witness

Your witnesses must declare that they personally know you and have adequate proof of your identity. The instructions stated below will apply to all of the parts of this section.

Witness signature

Have the witness affix his or her signature.

Date

Enter the current date of signing.

Witness name

Enter the full legal name of the witness.

Witness address

Enter the address of the witness.

City

Enter the city of the witness.

State

Enter the state of the witness.

ZIP code

Enter the ZIP code of the witness.

Notary Acknowledgement of Principal

The instructions stated below will apply to all parts of this section.

State of

Enter the state you are currently residing in.

County of

Enter the county you are currently residing in.

Date

Enter the current date of signing using the format: Day-Month-Year.

Signature

Have the notary public affix his or her signature.

Notary Public

Enter the full legal name of the notary public.

Commission Expiry Date

Enter the date when the notary public’s commission will expire.