North Carolina Medical Power of Attorney Form

The North Carolina medical power of attorney form is a document that is designed to provide a Principal written permission to one or more Agent’s to act on their behalf with regard to their health care in the event that the Principal is no longer able to communicate or make their own health care decisions. This document will grant the Agent broad powers over your health care. The best way to be certain that the Principal will continue to kno their wishes are honored, is to place their wishes, limitations and restrictions in writing. As well, if you find that your selected Agent is not working in the Principal may immediately revoke the document.

The Principal should review the entire document prior to completion. If any of the language is not clear, the Principal may choose to consult with an attorney for clarification.

This document must be signed by two witnesses and all signatures must be applied in the presence of a licensed Notary Public.

How to Write

Step 1 – Note and Explanation – The Principal must download the document and carefully review the first two sections.

Step 2 – Designation of Health Care Agent(s) –

  • Enter the Principal’s name -read the remainder of the paragraph, if in agreement:
  • Enter the name of the first agent the Principal would like to appoint – and the same information should be provided for all additional Agents, to serve consecutively:
  • Home Address
  • Home Telephone Number
  • Work Telephone Number
  • Cell Phone Number
  • Up to 3 Agents may be assigned on this document

Step 3 – Physician’s Signatures –

  • The Principal’s physicians must read the information and provide signatures in the lines provided

Step 4 – Revocation -The Principal should read the statement provided

Step 5 – General Statement of Authority Granted -Read all statements A throuh J

  • The Principal must review each statement. These statements are general, may be striken if the Principal wishes not to grant any specific power or, enhance, limit or restrict any of the statement and add special instructions .

Step 6 – Special Provisions and Limitations – The Principal must read the initial paragraph:

  • In each table provided, read the powers that the Principal would be able to grant or decline
  • In each power the Principal would like to approve, initial the line in the box on the left side of the power box
  • If the Principal would like to decline any of the powers, simply mark and “X” on the line to decline

Step 7 – Titled Sections – The Principal must read all remaining titles as follows:

  • Guardianship Provision
  • Reliance of Third Parties on Health Care Agent (A through B)
  • Miscellaneous Provisions – (A through E)

Step 8 – Signatures and Acknowledgement –

  • The Principal shall date the document in format
  • Enter the Principal’s Signature (The notary shall affix an official seal)
  • Enter the Principal’s name – read the remainder of the paragraph

Step 9 – Witnesses Signatures – The witnesses must enter the following in acknowledgement of the validity of this document:

  • Each witness must date their signature in mm/dd/yyyy format
  • Each witness must submit their respective signatures

Step 10 – Notarization –

When the document has been reviewed, completed and witnessed with dated signatures, the Notary Public, will complete the required information to validate the entire document.