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Medical Power of Attorney

Principal Name

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What is a Medical Power of Attorney?

A Medical Power of Attorney is a legal document that enables an individual to designate another person, known as an agent, to make healthcare decisions on their behalf in the event they become incapacitated and unable to make such decisions themselves. This document is crucial for ensuring that healthcare preferences are respected and that decision-making authority is clearly established during times when the individual cannot express their wishes. It is particularly important for individuals with specific medical conditions, those undergoing major surgery, or anyone who wishes to have control over their medical care decisions in future unforeseen circumstances.

Key Features

✓Allows the appointment of a trusted agent to make healthcare decisions on behalf of the principal.

✓Includes provisions detailing the scope of authority granted to the agent, from general healthcare decisions to specific interventions.

✓Can be customized to reflect the principal's healthcare preferences, including treatments they do or do not want.

✓Effective upon the occurrence of a condition specified by the principal, such as incapacity.

✓Provides peace of mind knowing that healthcare decisions will be made according to the principal's wishes.

✓Legally binding across healthcare facilities, ensuring compliance with the principal's directives.

Important Provisions

Identification of the Principal and Agent: Names and contact information for both parties involved.
Scope of Authority: Specific powers granted to the agent regarding healthcare decisions.
Conditions for Activation: Criteria under which the Medical Power of Attorney becomes effective, typically upon physician-certified incapacity of the principal.
Limitations and Exclusions: Any specific treatments or interventions the principal does not consent to, even if incapacitated.

Pros and Cons

Pros

+Empowers individuals to have control over their medical care through a trusted agent.
+Reduces family conflicts by clearly outlining who has decision-making authority.
+Ensures timely medical decisions can be made during critical moments without court intervention.
+Facilitates discussions about healthcare preferences and end-of-life care among family members.
+Can be revoked or amended by the principal at any time while they are still competent.

Cons

-Selecting an inappropriate agent could potentially lead to decisions contrary to the principal's wishes.
-May not cover all possible medical scenarios, requiring additional documentation like a living will.
-Requires careful drafting to ensure it is comprehensive and accurately reflects the principal’s desires.

Common Uses

Designating someone to make healthcare decisions when undergoing major surgery.
Appointing an agent in anticipation of a progressive illness leading to incapacity.
Ensuring someone with intimate knowledge of one's health preferences can make decisions in emergencies.
Allowing adult children to manage healthcare decisions for aging parents with declining mental faculties.
Providing instructions for healthcare management during terminal illness stages.

Frequently Asked Questions

Obtaining this document typically involves drafting it according to state laws, having it signed by the required parties, often in front of witnesses or a notary public. Consulting legal counsel can ensure it meets all legal requirements.

Yes, as long as the principal is still competent, they can revoke or amend their Medical Power of Attorney at any time.

The chosen agent should be someone trustworthy who understands the principal’s values and wishes regarding medical treatment. It’s also recommended that this person is capable of making potentially difficult decisions under pressure.

While it can include preferences on life-sustaining treatments, combining it with a living will explicitly covering end-of-life care ensures more comprehensive coverage.

Sample

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MEDICAL POWER OF ATTORNEY

This Medical Power of Attorney (hereinafter referred to as the "Document") is made and executed on .

DESIGNATION OF HEALTH CARE AGENT

I, , residing at , hereby appoint:

Name:
Address:
Phone:
Email:

as my agent (attorney-in-fact) to make any and all health care decisions for me, except to the extent I state otherwise in this document. This Medical Power of Attorney takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician.

ALTERNATE AGENTS

Add Alternate Agent?

FIRST ALTERNATE AGENT

If my agent is unable or unwilling to make health care decisions for me, I designate as my first alternate agent:

Name:
Address:
Phone:
Email:

Add Second Alternate Agent?

SECOND ALTERNATE AGENT

If my agent and first alternate agent are unable or unwilling to make health care decisions for me, I designate as my second alternate agent:

Name:
Address:
Phone:
Email:

AGENT'S AUTHORITY

My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:

WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE

Authority effective immediately

Authority effective upon physician's determination

My agent's authority becomes effective when my attending physician determines that I am unable to make my own health care decisions.

I want my agent's authority to begin now, even though I am still capable of making my own decisions.

AGENT'S OBLIGATIONS

My agent shall make health care decisions for me in accordance with this power of attorney, any instructions I give in this document, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

NOMINATION OF GUARDIAN

If a guardian of my person needs to be appointed for me by a court, I nominate my agent (or alternate) named above for appointment as guardian to serve without bond or security.

HIPAA RELEASE AUTHORITY

I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160-164, and the regulations promulgated thereunder. I authorize any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered healthcare provider, any insurance company, and the Medical Information Bureau, Inc., or other healthcare clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose, and release to my agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present, or future medical or mental health condition.

SPECIFIC MEDICAL DIRECTIVES

Include Life-Sustaining Treatment Preferences?

LIFE-SUSTAINING TREATMENT

If I am in a terminal condition with no hope of improvement:

I direct that life-sustaining treatment be withheld or withdrawn

I direct that life-sustaining treatment be continued as long as medically appropriate

I direct that my agent decide about life-sustaining treatment

Include Artificial Nutrition and Hydration Preferences?

ARTIFICIAL NUTRITION AND HYDRATION

Regarding artificial nutrition and hydration (food and water provided by feeding tube or intravenous line):

I direct that artificial nutrition and hydration be withheld or withdrawn

I direct that artificial nutrition and hydration be provided

I direct that my agent decide about artificial nutrition and hydration

Include Pain Relief Preferences?

RELIEF FROM PAIN

I direct that treatment for alleviation of pain or discomfort be provided at all times.

I direct that my agent decide about pain relief treatment.

Include Other Medical Wishes?

OTHER WISHES

I direct the following regarding my medical care:

ORGAN DONATION

Status:

I wish to be an organ donor.

I do not wish to be an organ donor.

I direct that my agent decide about organ donation.

ORGAN DONATION SPECIFICS

I wish to donate:

Any organs or tissues

Specific organs or tissues (specified below)

Specific organs or tissues I wish to donate:

For the following purposes:

Transplant

Therapy

Research

Education

Any purpose authorized by law

Governing Law

This Medical Power of Attorney is governed by the state laws of .

EFFECT OF COPY

A copy of this Medical Power of Attorney has the same effect as the original.

SIGNATURE

I sign my name to this Medical Power of Attorney on .

Principal Signature: ______________________________
Print Name: _______________

Include Witness Signatures?

WITNESS STATEMENT

I declare under penalty of perjury that the person who signed or acknowledged this document is personally known to me (or proved to me on the basis of satisfactory evidence) to be the principal, that the principal signed or acknowledged this Medical Power of Attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as agent by this document, and that I am not a health care provider, an employee of a health care provider, the operator of a community care facility, or an employee of an operator of a community care facility.

Witness #1 Signature: ______________________________
Print Name:
Address:
Date:

Witness #2 Signature: ______________________________
Print Name:
Address:
Date:

Include Notary Acknowledgment?

NOTARY ACKNOWLEDGMENT

State of
County of

On , before me, , personally appeared _______________, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that they executed the same in their authorized capacity, and that by their signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of _______________ that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Notary Public Signature: ______________________________

(Seal)

ACCEPTANCE BY AGENT

I accept this appointment and agree to serve as agent for health care decisions. I understand I have a duty to act consistently with the principal's desires as stated in this document or otherwise made known to me. I understand that this document gives me authority to make health care decisions for the principal only if the principal becomes incapacitated. I understand that I must act in good faith in exercising my authority under this power of attorney. I understand that the principal may revoke this power of attorney at any time in any manner.

If I choose to withdraw as agent, I must inform the principal of my decision. If the principal is not capable of understanding my withdrawal, I must inform the principal's caregivers of my withdrawal.

Agent Signature: ______________________________
Print Name: _______________
Date:

Alternate Agent Signature: ______________________________
Print Name: _______________
Date:

Second Alternate Agent Signature: ______________________________
Print Name: _______________
Date:

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About this document

A Medical Power of Attorney is a legal document that appoints a trusted person to make healthcare decisions on your behalf when you become unable to make or communicate those decisions yourself.

Create a Medical Power of Attorney

This document is designed to comply with the laws of all 50 states.

Updated Sep 07, 2025

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Legal Notice: Comments are personal opinions and do not constitute legal advice. Always consult a qualified attorney for matters specific to your situation.

Medical Power of Attorney

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This document is designed to comply with the laws of all 50 states.

Create a Medical Power of Attorney

Medical Power of Attorney

Principal Name

Not the form you're looking for?

What is a Medical Power of Attorney?

Key Features

Important Provisions

Pros and Cons

Pros

Cons

Common Uses

Frequently Asked Questions

Sample

MEDICAL POWER OF ATTORNEY

DESIGNATION OF HEALTH CARE AGENT

ALTERNATE AGENTS

AGENT'S AUTHORITY

NOMINATION OF GUARDIAN

HIPAA RELEASE AUTHORITY

SPECIFIC MEDICAL DIRECTIVES

ORGAN DONATION

Governing Law

EFFECT OF COPY

SIGNATURE

WITNESS STATEMENT

NOTARY ACKNOWLEDGMENT

ACCEPTANCE BY AGENT

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Do you have a question about a Medical Power of Attorney?

About this document

Community Discussion

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