Medical Power of Attorney Forms | PDF Templates

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