Colorado Medical Power of Attorney Form

The Colorado medical power of attorney form is a form that allows you to name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable of making your own decisions currently. This form may be revoked at any time, should you decide you would prefer to put it in place another time with another Attorney in Fact/agent. (See California Code Section 4700-4701)

How To Write

Step 1 – Appointment of Agent and Alternates – In this section, the Principal, known here as the “Declarant,” will record the person they would like to serve on their behalf with regard to keeping their health care decisions in order. Provide the following:

  • In the first blank line, enter the name of the Principal
  • Enter the name of the Attorney in Fact/Agent
  • Enter an email address and/or alternate telephone number for the agent
  • Enter the agent’s physical address
  • In the event the original agent is unable or unwilling to make health care decisions on behalf of the principal, the principal may choose to select and record an alternate agent. Provide the following:
  • Enter the name of the first alternate Attorney in Fact/Agent
  • Enter an email address and/or alternate telephone number for the first alternate agent
  • Enter the first alternate agent’s physical address
  • In the event the original agent or first alternate agent is unable or unwilling to make health care decisions on behalf of the principal, the principal may choose to select and record a second alternate agent. Provide the following:
  • Enter the name of the second alternate Attorney in Fact/Agent
  • Enter an email address and/or alternate telephone number for the second alternate agent
  • Enter the second alternate agent’s physical address

Step 2 – When the Agent’s Powers Begin – In this section, the principal will decide when they would like the powers for the agent to begin, by selecting and initialing the line before the selection as follows:

  • (Initials) Immediately upon my signature
  • (Initials) When my physician or other qualified medical professional has determined that I am unable to make or express my own decisions, and for as long as I am unable to make or express my own decisions.

Step 3 – Instructions to Agent(s) – The principal should read the paragraph provided with regard to their specific wishes and record those wishes in the lines provided. If more room is needed in order to be as specific as possible, add a sheet and attach it to this document.

  • Within these lines of instructions, state any desires the principal may have concerning life-sustaining procedures, treatment, general care and services, including any special provisions or limitations
  • Once the instructions have been recorded, the principal, must provide their signature on the form below the initial lines
  • Date the principal’s signature was recorded

Step 4 – Page 2. – Section 1 – Addendum to Medical POA – This is not required by law, although it is recommended. This section asks for signatures of the Agent and alternate Agents. Provide the following information:

  • First line in section 1 – Primary Agent and alternate agents must read the information in this area. Begin with placing the signature of the principal into the first line of the section
  • Primary Agent should read the remainder of the information provided and enter the following
  • Primary Agent’s Signature
  • Printed Name
  • Date Document was signed
  • Alternate Agent 1 – 
  • Alternate Agent #1 Signature
  • Printed Name
  • Date document was signed
  • Alternate Agent 2
  • Signature
  • Printed Name
  • Date document was signed

Step 5 – Page 2 – Section 2 – As stated, witnesses and notarization are not necessary for a medical power of attorney in the state of Colorado, however, it could be useful in other states if it happened to be needed while traveling or going to another state for treatment. Should you decide to use witnesses and a notary, provide the following:

  • First line is for the Principal’s signatue
  • Both witnesses should provide the following information
  • Signature of Witness
  • Printed Name
  • Physical Address

Step 6 – The remainder of the form will be completed by a notary public. After written completion, they will affix their state seal.

  • The notary will hand the document back to the principal
  • Copies should be made and provided to all who have signed the document as well, copies should be provided to physicians for their records