Oregon Medical Power of Attorney Form

The Oregon Medical Power of Attorney Form is a document that is designed to provide a Principal, the necessary documentation so that they may transfer powers of their health care to someone else, better known as an Agent or an Attorney In Fact. This document, inasmuch as it is a legal document that is meant to protect the Principal, if it’s not well composed, could significantly affect the Principal’s financial and real property and how it could be affected at the time that distribution begins. Therefore it’s very important that the Principal trusts the Agent that they select and be certain to discuss the Principal’s options with the Agent prior to completing the document.

This document requires that all signatories be present to sign the document in the witness of a licensed Notary. The Principal has the right to revoke this document at their discretion, providing notice is provided in writing and is delivered or served to the Agent(s).

How to Write

Step 1 – Advance Directive – Before proceeding, the Principal should begin by reviewing  the information on the first page as follows:

  • Facts About Part B (Appointing a Health Care Representative)
  • Facts About Part C (Giving Health Care Instruction)
  • Facts About Completing This Form

Step 2 – Principal’s Information – Enter the following information:

  • Principal’s name
  • Date of Birth in mm/dd/yyyy format
  • Complete address
  • AND

As long as this document is not revoked or suspended, select and initial one of the following, indicating how long the Principal prefers that this document will remain in effect:

  • Principal’s entire life
  • OR
  • Other Period (specify how many years the Principal would anticipate allowing the document to remain in effect)

Step 3 – Appointment of Health Care Agent – Provide the following information regarding the Agent:

  • Enter the name of the appointed Agent
  • Submit the Agent’s complete address
  • Provide the Agent’s telephone number
  • AND

In the event that the originally selected Agent is no longer able or willing to serve the Principal, the Principal may select an Alternate (Successor) Agent – The Agent may not be the Principal’s “doctor, an employee of your doctor, or an owner, operator or employee of your health care facility, unless that person is related to you by blood, marriage or adoption, or that person was appointed before your admission into the health care facility” With this information in mind, enter the following:

  • Enter the Alternate Agent’s full name
  • Alternate Agent’s complete address
  • Alternate’s telephone number

Limits –

  • Enter any special conditions or instructions that the Principal would like to convey in the lines provided

Initial the line –

  • If the Principal has executed a health care directive to their physicians and they expect the Agent to honor that directive provided to their physician

Life Support – Initial the line if the following applies -if it’s not initialed place an “X” in the line and the Agent will have to follow these instructions:

  • The Agent may make decisions regarding the Principal’s life support issues, if required

Tube Feeding – Initial the line if the following applies -if it’s not initialed place an “X” in the line and the Agent will have to follow these instructions:

  • The Agent may make decisions regarding tube feeding for the Principal’s comfort, if required
  • Date in which this section has been completed in mm/dd/yyyy format

Appointment of a Health Care Representative –

  • Should the Principal choose to assign a Physician – the Physician must enter their signature on the line provided in this section

Step 4 – Health Care Instructions – The Principal, should they wish to make their decisions with regard to their treatment when they are near death, initial one of the lines below each subject as follows:

  • I want to receive tube feeding
  • I want tube feeding only as my physician recommends
  • I DO NOT WANT tube feeding
  • AND
  • I want any other life support that may apply
  • I want life support only as my physician recommends
  • I want NO life support

Make selections from the same example in the following:

  • Permanent Unconscious
  • Advanced Progressive Illness
  • Extraordinary Suffering

Initial and provide a description if the following applies:

  • “I do not want my life to be prolonged by life support. I also do not want tube feeding as life support. I want my doctors to allow me to die naturally if my doctor and another knowledgeable doctor confirm I am in any of the medical conditions listed in Items 1 to 4 above.”
  • Additional Conditions or any Instructions. (Insert description of your choices in the lines provided)

Other Documents – Initial one of the following:

  • I have previously signed a health care power of attorney
  • I want it to remain in effect unless I appointed a health care representative after signing the health care power of attorney
  • I have a health care power of attorney, and I REVOKE IT
  • I DO NOT have a health care power of attorney
  • Date the section in mm/dd/yyyy format
  • Provide Principal’s Signature

Step 5 – Declaration of Witnesses – Witnesses must read the statements provided. Only one of the two witnesses may be blood related to the Principal, the other must not be related or have any interest in the Principal’s estate. Once the witnesses have read the statement and agree, they must enter the following:

  • Witnesses Signatures
  • Date each respective signature in mm/dd/yyyy format
  • Each witness must enter their printed name in the line next to their dated signatures

Step 6 – Acceptance by Health Care Agent – The Agent and the Alternate Agent, must carefully review the acceptance statement. If after reading the statement they are in agreement, the Agent and Alternate, must provide the following:

  • Agent’s Signature – Date the signature in mm/dd/yyyy format
  • Alternate/Successor Agent’s Signature – Date of the Alternate’s signature in mm/dd/yyyy format