 | Utah Medical Power of Attorney Form |
The Utah medical power of attorney form is a legal document that provides the opportunity for a Principal to delegate an Agent to make decisions with regard to the health care of the Principal when they are no longer able to communicate their own decisions and wishes. The Principal will complete the form, outlining their health care decisions while they are of sound mind.
Prior to completion of this form, the Principal should consider reading this document to ensure that they are clear with regard to it’s meaning. If the Principal is unsure of any portion of the document, they may wish to consider contacting an attorney for legal advice (if needed).
This document must be signed in the presence of and by a witness. This document may also be revoked by written notice and either delivery or service to the Agent(s) (The notice is not considered valid until the current Agent has received the revocation notice)
How to Write
Step 1 – Principal’s Personal Information – Complete the following:
- Principal’s Name
- Street Address
- City, State, Zip Code
- Telephone
- Cell Phone
- Principal’s Date of Birth in mm/dd/yyyy format
Step 2 – Appointed Agent’s and Alternate Agent’s Information – In section A, if the Principal chooses not to appoint an agent at all, initial the box provided. Otherwise provide the following:
Section B – First Selected Agent:
- Agent’s Name
- Street Address
- City, State, Zip Code
- Telephone
- Cell Phone
- Agent’s Date of Birth in mm/dd/yyyy format
Section C – Alternate Agent’s Information (Optional) – Enter:
- Alternate Agent’s Name
- Street Address
- City, State, Zip Code
- Home Phone
- Cell Phone
- Work Phone
Section D – The Principal and Agent(s) should review the information in this section before proceeding:
Section E – Other Authority –
- The Principal must read the statements in Sections E through I and initial either “yes” or “no” depending upon the preference of the Principal
Section F- Limits/Expansion of Authority –
- In this section, the Principal will have the opportunity to limit or provide information with regard to further wishes as to how they would like to have their health care attended to when they are no longer able to express their wishes.
Section G – Nomination of Guardian –
- In the event that the initially appointed Agent is unable or unwilling to properly act on behalf of the Principal, the courts may be in a position to appoint a new guardian if the Principal becomes unwilling to communicate and direct their own health care. If the Principal would like to nominate the appointment of their Successor Agent to act on their behalf, initial the line preceding “yes” so that the courts will be able to consider someone who intends to follow the Principal’s directive, someone that the Principal has indicated, should step in, if needed.
Section H – Consent to Participate in Medical Research –
- This section would allow the Principal to provide permission for their Agent to consent to medical research trial, even if the end results are not beneficial to the Principal
Section I – Organ Donation –
- The Principal should indicate whether or not they would have the desire to allow their Agent to consent to organ donation for transplantation
The Principal must sign their name at the end of this section
Step 3 – Principal’s Health care Wishes ( Living Will) –
The Principal will find four (4) options pertaining to their current wishes. Read each option carefully and select only one. If there are additions to be made in the box containing the Principal’s selection, complete the requested information:
- Option 1 – Allow the Agent to Decide
- Option 2 – Choose to Prolong Life
- Option 3 – Choose Not to Receive Care to Prolong Life
- Option 4 – Choose Not to Provide Preferences in this Document
The Principal must sign their name at the end of this section
Step 4 – Additional Instructions –
- The Principal may enter any additional instruction with regard to their health care wishes, by entering the information into the lines provided on the form
Step 5 – Revocation Information –
- The Principal should review this section in the event they would choose to revoke this document
Step 6 – Legalizing the Directive -The Principal must carefully review the statement. If in agreement:
- Date the signature in mm/dd/yyyy format
- The Principal must submit their signature
- The Principal must enter their City, County, and State of Residence
Step 7 – Witness Acknowledgement – The witness must read and agree to statements 1 through 8 – The witness must then provide:
- Witness Signature
- Printed Name
- Street Address
- City
- State
- Zip Code
- If the witness is signing to also indicate any verbal directives, the witness must enter a brief description with regard to the circumstances in which any oral directive was created
The Principal must sign their name to this section
