South Carolina Medical Power of Attorney Form

The South Carolina medical power of attorney form is a document that a Principal would use to provide powers to an Agent so that they may make decisions for the Principal in the event the Principal becomes incapacitated to the point that they may no longer communicate their health care choices. The Principal may choose, and may, limit or restrict any of the powers they wish.

The Principal should discuss their health care choices with their selected Agent. They should also carefully review the entire document prior to completion, to ensure that all aspects are fully understood. If the Principal doesn’t understand any of the document, they may choose to contact an attorney for a better understanding of the document before committing to it.

This document must be signed by two witnesses OR it must be acknowledged by a licensed Notary Public. The document may also be revoked at any time at the discretion of the Principal. This may be accomplished by providing written notice to the Agent(s) and having it delivered or served to the Agent(s)

How to Write

Step 1 – Information About The Document –

  • The Principal should download the document and read through it completely before the complete it.

Step 2 – Designation of Agent – The Principal may appoint their Agent by entering the following information:

  • Enter the name of the Principal
  • Submit the Agent’s name
  • Agent’s Address
  • Agent’s home phone
  • Work phone
  • Mobile phone

Step 3 – Designation of Successor Agent(s) – The Principal, in the event the initial Agent should become unable or unwilling to act on their behalf, may also elect Successor Agents to serve consecutively. Enter the Successor Agents in the order the Principal would like them to serve – Enter the following:

  • First Alternate Agent’s Name –
  • Address
  • Home Phone
  • Work Phone
  • Cell Phone
  • AND
  • Second Alternate Agent’s Name –
  • Address
  • Home Phone
  • Work Phone
  • Cell Phone
  • The Principal should read the remaining paragraph regarding the Successor Agents

Step 4 – Titled Sections – The Principal should read all of the following titles:

  • Effective Date and Durability
  • HIPPA Authorization
  • Agent’s Powers (also read A through E in this category)
  • In Section E – The Principal may limit. restrict or eliminate any of the stated powers

Step 5 – Organ Donation – The Principal must initial only one of the following options:

  • The Agent may –
  • OR
  • may not -consent to the donation of all or any tissue or organs for purposes of transplantation
  • Read the following two titles:
  • Effect on Declaration of Living Will
  • Statement of Desires Concerning Life Sustaining Treatment

Step 6 – Decisions for Life Sustaining Treatment –

Read the following 3 paragraphs. Select only one, by initialing the preceding line as follows:

  • Grant of Discretion to Agent
  • OR
  • Directive to Withhold or Withdraw Treatment
  • OR
  • Directive for Maximum Treatment

Step 7 – Statement of Desires Regarding Tube Feeding – Initial only one from the following 3 paragraphs:

  • Grant of Discretion to Agent
  • OR
  • Directive to Withhold or Withdraw Treatment
  • OR
  • Directive for Maximum Treatment

Step 8 – Administrative Provisions –

  • The Principal must read this section regarding decisions for revocation

Step 9 – Signatures – Must be witnessed by witnesses or acknowledged by a licensed Notary:

  • Date the Principal’s Signature and information in dd/mm/yy format
  • Enter the Principal’s current address
  • Principal’s Signature
  • Principal’s Printed Name

Step 10 – Witness’ Attestation – If the Principal shall choose two witnesses to sign this document, the witnesses must read the attestation paragraph prior to providing information:

  • Witness Number 1
  • Signature
  • Date
  • Print Name
  • Telephone
  • Address
  • AND
  • Witness Number 2
  • Signature
  • Date
  • Print Name
  • Telephone
  • Address
  • OR –

Notarization –

  • Should the Principal select acknowledgement of a licensed Notary Public, once the notary has witnessed all required signatures, the Notary shall complete the required acknowledgement information, also affixing their official seal