North Dakota Medical Power of Attorney Form

The North Dakota medical power of attorney form is a complete packet of documents that will cover literally every aspect of what a Principal would need to communicate with regard to their health care, while they are of sound mind, to instruct, Agents, family members, and health care professionals of their wishes.

Due to the length of the packet, it’s recommended that the Principal consider a consultation with an attorney to ensure that they are properly educated with regard to all of these instructions contained within these pages. These documents will not provide any Agent or anyone, access to the Principal’s personal property, real property, financial information, or accounts.

At completion, these documents, collectively, must be signed before a Notary Public or two witnesses. These documents may also be revoked by the Principal at any time, in writing and by delivery as notice to the Agent(s)

How to Write

Step 1 – Documents –

  • The Principal must download the packet of documents.
  • Before proceeding they must review pages 1 titled Advance Directives for ND and page 2, The Living Will Declaration

Step 2 – Health Care Directive –

  • Enter the name of the Principal
  • The Principal must then read all of the remaining paragraphs pertaining to the directive

Step 3 – Appointment of Health Care Agent –

  • The Principal must carefully read the instructions in this section and clearly discuss the appointment with the selected Agent
  • Enter the name of the Agent in the line provided
  • Enter the relationship of the Agent to the Principal
  • Provide the telephone number of the appointed Agent
  • Provide the full address of the appointed health care Agent
  • AND

Appointment of an Alternate Agent in the event that the original Agent is unable to serve:

  • Enter the relationship of the Alternate Agent to the Principal
  • Enter a telephone number for the Alternate
  • Provide a complete address for the Alternate Agent

It is very important that the Principal carefully review the information provided in the paragraphs prior to proceeding:

  • After reading all of the possibilities, should the Principal choose to limit, restrict or deny any of the stated powers, provide that information in the lines provided. If more room is required, add a continuation on a separate sheet. Once the continuation is completed, the Principal must sign and date the additions on the separate sheet to ensure that it becomes a legal portion of the main document
  • Regarding the Principal’s choices with regard to disposition of their remains, the Agent will only be able to make any decisions if there are no initials proceeding the statement. If the Principal would like to exclude any of the powers entirely, place an “X” in the line.

Step 4 – Health Care Instructions – Complete the following, in the lines provided, so that  health care providers and Agent(s) will know exactly what the Principal desires as needed – Answer the following:

  • Principal’s  goals for my health care
  • Principal’s  fears about their health care
  • Principal’s spiritual or religious beliefs and traditions
  • Principal’s  beliefs about when life would be no longer worth living
  • Principal’s  thoughts about how their medical condition might affect their family

Step 5 – Health Care Do’s and Don’t(s) –

The Principal should read the information at the top of this section:

  • Once the section has been reviewed, the Principal may then read each statement and answer them in the lines provided for each

Step 6 – Making an Anatomical Gift –

The Principal should only complete this section if they have the desire to participate in organ donations.

  • If the Principal would like to participate in this action, check the box that indicates how you would like to donate
  • Provide the date in mm/dd/yyyy format
  • City
  • State
  • Principal must provide their signature, before witnesses (who must sign the document or a notary

None of the following are acceptable as witnesses:

  • 1. A person you designate as your agent or alternate agent
  • 2. Your spouse
  • 3. A person related to you by blood, marriage, or adoption
  • 4. A person entitled to inherit any part of your estate upon your death
  • 5. A person who has, at the time of executing this document, any claim against your estate

Step 7 – Select your witness option, Notary Public or Two Unrelated and Uninterested Witnesses –

  • Implement your option by provision of signatures as instructed

Step 8 – Acceptance of Appointment of Health Care Agent –

  • Both the selected Agent and the Alternate Agent, must carefully read the paragraph in this section
  • If in agreement, they must enter their respective signatures
  • Date their signatures on the same respective signature line in mm/dd/yyyy format

Principal’s Statement – Principal must read the statement. Enter the following:

  • The Date of the Principal’s signature in dd/mm/yyyy format
  • Principal must enter their signature

Step 9 – Statement Affirming Explanation of Document to Resident of Long Term Care Facility – This document provides information to a Long Term Care Facility, in the event the Principal must be placed – Provide the following:

  • Enter the name(s) of the person(s) who are in full knowledge of the Principal’s directives
  • Principal’s Name
  • Enter the name of the City where the facility is located
  • Check the box that best describes the person in receipt of this document
  • Date the statement(s) in dd/mm/yyyy format
  • Provide the signature of the recipient

Step 10 – Statement Affirming Explanation of Document to Hospital Patient or Person Being Admitted to the Hospital – The Principal must read the statement provided then complete the following fields –

  • Enter the name of the Principal
  • Enter the name of the admitting hospital
  • Check the box that best describes the person to provide explanation
  • Enter the date of explanation in dd/mm/yyyy format
  • Signature of the person providing explanation of the directive