 | South Dakota Medical Power of Attorney Form |
The South Dakota medical power of attorney form is is a legal document that will allow a Principal to designate and Agent to make health care decisions on their behalf, so that, in the event that the Principal is no longer able to communicate their own health care decisions on their own there will be an Agent available to step in to assist the health care provider(s). The document will only allow the powers that the Principal chooses specifically. This document will offer no powers over the finances, personal property or real property, to the Agent.
The document should be carefully reviewed, prior to completion. If it’s not clear to the Principal, they should consider speaking with an attorney to ensure proper education with regard to completion of this document.
This document may be revoked at any time, in writing, by the Principal and by delivery to the Agent. The document must also be witnessed by two (2) witnesses or in the presence of a licensed Notary Public.
How to Write
Step 1 – Designation of Agent – Enter:
- The Principal’s name
- The Agent’s name
- Agent’s Address
- Agent’s Home phone
- Agent’s Work Phone
Step 2 – Titled Sections – Must Review prior to proceeding:
- Effective Date and Durability
- Agent’s Powers
- Agent’s Authorized Powers (unless otherwise stated by the Principal in this document) – Read A through H
Step 3 – Statement of Desires, Special Instructions, and Limitations –
- The Principal must enter any power that must be limited, restricted or are not listed and must be recognized, in the lines provided
Step 4 – Life Sustaining Information (Living Will) –
- The Principal shall read each of the powers listed and initial the powers that they wish their Agent to enact in the event they are unable to communicate their wishes – Choose from the following:
- Reference to Living Will
- Grant of Discretion To Agent
- Directive To Withhold or Withdraw Treatment
- Directive For Maximum Treatment
- Directive In My Own Words – If the Principal would like to produce their directive on their own, they may enter their directive in the lines provided
Step 5 – Nutrition and Hydration –
- Principal must read the selections and initial their selection
Step 6 – Alternate Agents – If the initial Agent for whatever reason is no longer able to serve, the Principal may choose to elect other Alternate Agents (optional) If so, enter the following information:
- First Alternate Agent
- Address
- Telephone
- AND
- Second Alternate Agent
- Address
- Telephone
Step 7 – More Titled Sections – The Principal must read the following information:
- Protection of Third Parties Who Rely On The Agent
- Nomination of Guardian
- Administrative Provisions – A through D
Step 8 – Signatures – To be signed before witnesses or a Notary Public –
- Principal must date their information as follows in dd/mm/yy format
- Current Address
- Date of Birth in mm/dd/yyyy format
- Enter Principal’s signature
- Printed name of Principal
- AND
Witness Statement and Signatures – The Witnesses must read the attestation and provide the following (respectively)
- Witnesses Signatures
- Witnesses Addresses
- OR
Notarization –
- If the selection will be notarization, once the Notary Public has witnessed the Principal’s Signature to the completed document, the Notary is then required to provide all of their state required acknowledgement.
