	Medical Power of Attorney Forms \| PDF Templates
	Adobe PDF MS Word

Medical Power of attorney is a designation given to a specific individual for the health care decision-making when a person can no longer think for themselves. The caregiver will be granted the task of making everyday hospital decisions with the best intentions of the patient.

Advance Directive – Living Will + Medical Power of Attorney

Living Will – A living will is a declaration that is made by a person to the hospital staff of their intentions if they should be deemed incapacitated or considered in end-of-life care. This allows the patient, to select ahead of time, whether they should wish to refuse artificial feeding and/or hydration in order to die a natural death.

Living Will vs. Power of Attorney – A living will outlines a patient’s intentions for end of life treatment without the use of a caregiver. A power of attorney is gives responsibilities to someone else to handle a patients end of life choices.

Medical Forms by State

How to Write

Step 1 – Important Information – Review:

The Principal must carefully read and review the information provided on the first page of the document prior to completion and application of signature

Step 2 – Appointment of Health Care Agent – Enter the parties information as follows:

Principal’s full name
Street address
City
State
AND
Agent’s full name
Street address
City
State
Principal should carefully review the remainder of this section
Agent’s home phone number
Work phone number
Cell phone number
E-mail address

Step 3 – Limitations on Agent –

Enter any limitations or exceptions into the lines provided in this section (if more room is needed, add a continuation sheet. Sign and date the additional sheet and attach to this document)

Step 4 – Appointment of Alternate Agents – If the Principal wished to add alternate agents in the event the initial agent is ever unwilling or unable to act on their behalf, enter the following information:

Name of First Alternate Agent
Address
Phone number
AND
Name of Second Alternate Agent
Address
Phone number

Step 5 – Original and Copies of this Document –

In the lines provided, enter the locations where this document shall be filed
Also, provide a list, in the lines provided, of others who shall be supplied copies of the powers of the medical document

Step 6 – Duration – The document shall remain in effect until revocation.

Should the Principal prefer to state the date of revocation, initial and check the box
Enter the preferred date of expiration in dd/m/yy format

Step 7 – Execution of the Document – Enter the following information:

Date signatures in dd/m/yy format
City
State
AND
Principal’s signature
Printed name
AND
Agent’s signature
Printed name
AND
1st Alternate Agent’s signature
Printed name
2nd Alternate Agent’s signature
Printed name

Step 7 – Witness of Document –

Notary shall witness all signatures
Notary shall complete this section by completing the remaining required information in acknowledgement

Witnesses Affirmation – Witnesses must review the statement and provide their respective information as follows:

Signatures of Witnesses
Printed name(s)
Date of signature(s) in mm/dd/yyyy format
Addresses

Medical POA – Adobe PDF – Microsoft Word (.docx)

Medical Power of Attorney Forms | PDF Templates

Medical Forms by State

How to Write