Fillable Form Minnesota Durable Power of Attorney for Health Care Decisions

What is the Minnesota Durable Power of Attorney for Health Care Decisions?

The Minnesota Durable Power of Attorney for Health Care Decisions is a legal document allowing an individual, called the Principal, to designate a “health care agent” to make health care decisions on their behalf. Health care agents are usually trustworthy relatives or friends.

The Durable Power of Attorney for Health Care Decisions in Minnesota is used when a patient is unconscious or incapacitated to make such decisions. This form is used alongside a living will, which details the principal’s end-of-life and health care preferences, such as the use of artificial respirators.

The State of Minnesota Durable Power of Attorney for Health Care Decisions is effective until you make any amendments or cancel it.

You may download a PDF copy of the Minnesota Durable Power of Attorney for Health Care Decisions Template from websites that offer document templates. But you may electronically fill it out on PDFRun for your convenience.

How to fill out the Minnesota Durable Power of Attorney for Health Care Decisions?

Enter the necessary information in the required fields of the Minnesota Durable Power of Attorney for Health Care Decisions PDF. Make sure that everything you enter is true, accurate, and correct.

General Statement of Authority Granted

Name of the Principal

Enter your full legal name,

Agent’s Full Legal Name

Enter the agent’s full legal name.

Agent’s Address

Enter the agent’s complete address.

Agent’s Telephone Number

Enter the agent’s telephone number.

Agent’s Email Address

Enter the agent’s email address.

This statement of authority states that the principal trusts and appoints an agent to make health care decisions on their behalf. The agent is authorized to do the following:

• Consent, refuse consent, or withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or medical condition, and to make decisions about organ donation, autopsy, and disposition of the body.
• Make necessary arrangements at any hospital, psychiatric hospital, or treatment facility; to employ or discharge health personnel as the Agent shall deem necessary for the principal’s mental, physical, and emotional well being; and
• Request, receive and review any information regarding the principal’s personal affairs or physical or mental health including medical and hospital records, and execute any releases of other documents that may be required to obtain such information.

The next is an optional section. It states that if the principal’s health care agent is not reasonably available, they trust and appoint the individual entered below to be their Agent instead.

Agent’s Full Legal Name

Enter the agent’s full legal name.

Agent’s Address

Enter the agent’s complete address.

Agent’s Telephone Number

Enter the agent’s telephone number.

Agent’s Email Address

Enter the agent’s email address.

Authority of the Agent

Enter the agent’s authority or other special instructions under this form.

Limitations of Authority

This section states the Agent shall be limited to the extent set out in writing in the Minnesota Durable Power of Attorney for Health Care Decisions. It shall not include the power to revoke or invalidate any previously existing declaration made in accordance with the natural death act.

Prohibition

Enter the Agent’s prohibitions from authorizing consent.

Additional Limitations

Enter the additional limitations of the Durable Power of Attorney for Health Care Decisions in Minnesota.

Revocation

This section states that any durable power of attorney for health care decisions the principal had previously made is revoked. The revocation must be in writing executed, witnessed, or acknowledged in the same manner as required in this form or other manner of revocation.

Execution Date

Enter the execution date.

Location

Enter the location this form was executed.

Signature of Person Making Declaration (Principal)

Affix your signature.

Type or Print Name of Principal

Enter your full legal name.

Address

Enter your complete address.

Witnesses

This section states that two witnesses must sign the MN Durable Power of Attorney for Health Care Decisions. Only one of the two witnesses can be a healthcare provider or an employee of a healthcare provider giving direct care to the principal on the day the principal signs this document.

Witness One and Witness two have four parts:

• In the witness’s presence, the person acknowledged the signature on the document or acknowledged that they authorized the person signing the document to sign on their behalf;
• That they are at least 18 years of age;
• That they are not named as a health care agent or an alternate health care agent in this document; and
• If they are a health care provider or an employee of a health care provider giving direct care to the principal, they must initial the box.

Witness One

Date

Enter the date.

Name

Enter the name of the person acknowledging their signature on this document.

Initial

Enter the initials if Witness One is a health care provider or an employee of a health care provider.

Signature of Witness # 1

Have the Witness One affix their signature.

Type or Print Name of Witness # 1

Enter the name of Witness One.

Address

Enter the address of Witness One.

Witness Two

Date

Enter the date.

Name

Enter the name of the person acknowledging their signature on this document.

Initial

Enter the initials if Witness Two is a health care provider or an employee of a health care provider.

Signature of Witness # 2

Have the Witness Two affix their signature.

Type or Print Name of Witness # 2

Enter the name of Witness Two.

Address

Enter the address of Witness Two.

How to file the Minnesota Durable Power of Attorney for Health Care Decisions?

Once you have signed the Minnesota Durable Power of Attorney for Health Care Decisions Form, inform the others and provide copies to them. You can also inform your family members, healthcare agents, and healthcare providers and give them a copy as well.

Take note that the State of Minnesota Durable Power of Attorney for Health Care Decisions must be signed by the Principal. It must also either be witnessed by two witnesses or verified by a notary public. In either case, it must be dated when it is verified or witnessed.