Ohio Medical Power of Attorney Form

The Ohio medical power of attorney form is a document that a Principal will provide to an appointed Agent, to provide them all of the information needed for the Agent to properly honor the health care wishes for the Principal. The document doesn’t take effect until the Principal is no longer able to communicate their wishes or make decisions with regard to the direction of their health care any longer, whether temporarily or permanent. The Principal should take great care in the selection and appointment of their Agent.

This document is lengthy in nature and will take time to carefully review the entire document, however, it is important to do so. It’s recommended, if the Principal is uncertain of any portion of the information contained within these pages, that the Principal consider working with an attorney who would be able to make clear to the Principal, what actions they are choosing and signing . To ensure that more than just your Agent, has a copy of your document, it’s also important that you speak to other people of this document and even provide copies to others, despite the fact that others will not have the ability to act on your behalf. However, if your Agent is not honoring your document to the letter, you will have others who may help in making certain that the document is followed according to the Principal’s wishes or take further collective actions. File a copy of this document with the county recorder’s office for safety.

This document will require signatures of unrelated/uninterested witnesses OR they may use the services of a Notary Public.This document may be revoked at any time. Place the revocation in writing, have it notarized and delivered or served to the Agent. The Principal may also name a new Agent and create a new document which would immediately, as of the date of the new document,this will revoke this particular document.

How to Write

Step 1 – Establish the Ownership of the Document –

  • At the top of page one, print the full name of the Principal
  • Enter the Principal’s date of birth in mm/dd/yyyy format

Step 2 – Definitions – The Principal must consider reading all of the definitions to ensure they are aware of the legal and medical meanings of the terms/ Review the following definitions:

  • Agent or attorney-in-fact
  • Anatomical gift
  • Artificially or technologically supplied nutrition or hydration
  • Cardiopulmonary resuscitation or CPR
  • Comfort care
  • Donor Registry Enrollment Form
  • Do Not Resuscitate or DNR Order
  • Health care
  • Health Care Power of Attorney
  • Life-sustaining treatment
  • Living Will Declaration or Living Will
  • Permanently unconscious state
  • Principal
  • Terminal condition or terminal illness

Step 3 – Naming of the Agent – Submit the following information:

  • Agent’s full name
  • Agent’s Current Address
  • Agent’s Current Telephone Number

Step 4 – Naming of Alternate Agent(s) (Optional) –

If the original Agent is found to be unable to act on behalf of the Principal, the Principal may wish to assign alternates. This is optional. If the Principal would like to assign alternates enter the following:

  • Enter the name of each Agent (respectively)
  • Agent’s addresses
  • Agent’s telephone numbers

Step 5 – Titled Sections – The Principal must take the time to review all of the titles sections as follows:

  • Guidance to Agent
  • Authority of Agent – (1st paragraph and sections 1 through 10 and number 11 A through C)
  • Special Instructions ( 1 through 3 and initial at number 3 of this is the choice of the Principal)
  • Limitations of Agent’s Authority (paragraphs 1 through 5)
  • Additional Instructions or Limitations – (The Principal may give additional instructions or impose additional limitations or restrictions for the observation of the Agent as decisions are made on their behalf) Use the lines on the form to properly instruct the Agent in writing.
  • No Expiration Date
  • Guardian
  • Enforcement by Agent
  • Release of Agent’s Personal Liability
  • Copies the Same as Original
  • Out of State Application
  • Living Will – (Principal must indicate if a living will exists – attach a copy to these document)
  • Anatomical Gift(s) – (Principal must indicate if this documented action exists – attach a copy to these document)
  • Donor Registry Enrollment Form (Principal must indicate if this documented action exists – attach a copy to these document)

Step 6 – Signature (s) – The Principal must read the statement and enter the following before a licensed Notary Public OR Two Witnesses:

  • Date the completed document in mm/dd/yyyy format
  • City of execution of the document
  • The Principal must submit their signature

Step 7 – Witness Attestation OR Notary Acknowledgement – The Principal may use two independent witnesses OR the services of a Notary OR both should they so desire:

Witnesses must read the attestation. If the witnesses are in agreement with  the statement, submit the following information:

  • Witnesses respective signatures
  • Physical addresses
  • Printed names
  • Date of the witnesses signatures

Notarization OR Witnesses –

If the Principal would prefer to use a notary, their signature must be witnessed by the notary. The Notary shall then acknowledge the document by completing the Notary section of the document.

Step 8 – Notice to Adult Executing This Document –

  • The remaining pages are vital to read and review before presentation of documentation to an Agent or anyone else
  • Again – If the Principal is not sure of the meaning of even one portion of this document, a knowledgeable attorney is recommended to assist in explanation any or all of the document.