Medical Power of Attorney (Designation of Health Care Agent)
I, [Your full name], born [Your date of birth], residing at [Your address] (the “Principal”), being of sound mind and at least eighteen years of age, make this Medical Power of Attorney (the “Power”) voluntarily. By this Power I appoint a health care agent to make decisions about my medical care if I become unable to make or communicate them myself. I understand that this Power is durable, meaning it continues to be effective after I lose capacity, which is the reason I am making it. It does not give anyone authority over my money or property.
1. Designation of Agent
I designate [Health care agent: name], my [Agent: relationship to you], of [Agent: address], telephone [Agent: phone], as my health care agent (the “Agent”) to make health care decisions for me as authorised in this Power.
2. Alternate Agents
If my Agent is not willing, able or reasonably available to make a decision for me, or if my Agent is my spouse and our marriage is dissolved or annulled, I designate [First alternate agent: name], telephone [First alternate: phone], as my first alternate agent. If my first alternate is also not willing, able or reasonably available, I designate [Second alternate agent: name (or “None”)], telephone [Second alternate: phone (or “None”)], as my second alternate agent. An alternate who acts has every power granted to my Agent, and a health care provider may rely on the alternate’s statement that the prior agent is unavailable.
3. Authority of Agent
My Agent may make every decision about my health care that I could make myself if I had capacity, including: consenting to, refusing or withdrawing any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition; consenting to, refusing or withdrawing artificial nutrition and hydration, mechanical ventilation, dialysis, cardiopulmonary resuscitation and every other form of life-sustaining treatment; requesting a do-not-resuscitate or portable medical order; selecting, employing and discharging physicians, nurses, therapists and other providers; admitting me to or discharging me from any hospital, nursing facility, assisted living, hospice or other facility, including for mental health treatment where the law allows an agent to consent; approving or refusing participation in research; and signing releases, consents, waivers and other documents needed to carry out these decisions.
4. When Authority Begins
My Agent’s authority becomes effective: [When your agent’s authority takes effect]. If it depends on a determination that I cannot make my own decisions, that determination shall be made by my attending physician and entered in my medical record, and my Agent may ask for it. While I am able to make and communicate my own decisions, my own decisions control and my Agent shall consult me and defer to me. If I regain capacity, my Agent’s authority is suspended until I again lose it.
5. Limits on Authority
My Agent’s authority is subject only to the following limits: [Limits on your agent’s authority (or “None”)]. My Agent may not consent on my behalf to anything I could not consent to myself, and may not override a decision I make while I have capacity.
6. Guidance to My Agent
My Agent shall make decisions in accordance with my written instructions, including any living will or advance directive I have signed, and my other wishes to the extent known to my Agent. Where my wishes are not known, my Agent shall decide according to what my Agent determines in good faith to be in my best interest, considering my personal values. To help my Agent, I state the following about my values and priorities: [Guidance for your agent: your values and priorities (or “None”)]. My religious or cultural preferences relevant to my care are: [Religious or cultural preferences (or “None”)]. My Agent has no liability for a decision made in good faith under this Power.
7. Access to Medical Information
I authorise every health care provider, health plan and facility to disclose my protected health information, including my diagnosis, prognosis, test results, treatment options and records, to my Agent and alternate agents, and to discuss my condition with them, so that they can carry out this Power. I intend my Agent to be treated as my personal representative under the Health Insurance Portability and Accountability Act of 1996 and 45 CFR §164.502(g). This authority is effective immediately on signing, whatever I have chosen in Section 4, so that my Agent can determine whether my incapacity has arisen, and it continues after my death for the purpose of Section 8.
8. Authority After Death
Unless I have provided otherwise in a will or other signed writing, my Agent may make anatomical gifts of my organs, tissues and parts, authorise an autopsy, and direct the disposition of my remains, and may sign every document needed for those purposes.
9. Nomination of Guardian
If a court ever needs to appoint a guardian or conservator of my person, I nominate my Agent, and if my Agent cannot serve, my alternate agents in the order named. This Power shall not be terminated by that appointment unless the court so orders.
10. Revocation; Prior Documents
I revoke every prior medical power of attorney, health care proxy or designation of a health care agent to the extent it is inconsistent with this Power. I may revoke this Power at any time while I have capacity, by a signed writing, by executing a new power, or by telling my attending physician in person; revocation is effective as to a provider when the provider has actual notice of it. If I have named my spouse as Agent and our marriage is dissolved or annulled, that designation is revoked and my first alternate becomes my Agent unless I provide otherwise in writing.
11. Reliance; Copies
A health care provider or facility that acts in good faith reliance on this Power, or on the decision of my Agent under it, is released from liability to me and my estate to the same extent as if I had made the decision myself. A provider unwilling to comply with my Agent’s decision for reasons of conscience shall promptly say so and assist in my transfer to a provider who will comply. A photocopy, scan or electronically signed copy of this Power has the same effect as the original.
12. Governing Law; Severability; Electronic Signature
This Power is made under the laws of the State of [Governing law (state)]. I intend it to be honoured in every state as a document validly executed under that state’s law or under the law of my domicile. If any provision is held invalid, the remaining provisions shall be given full effect. This Power may be signed electronically, and the electronic execution record, timestamps and document fingerprints kept by the signing platform are evidence of execution; where the law of my state requires wet-ink signatures or a notarial acknowledgment, I intend to complete those formalities on a printed copy, and that copy shall be my Power.
13. Signature and Statement of Witnesses
13.1 Signature. I sign this Medical Power of Attorney on the date shown in the execution record, having read it and understood it, freely and without duress or undue influence.
13.2 Statement of witnesses. Each witness, by signing below, declares that: (1) the Principal is personally known to me or proved their identity to me by satisfactory evidence; (2) the Principal signed or acknowledged this Power in my presence and appeared to be of sound mind and under no duress, fraud or undue influence; (3) I am at least eighteen years of age; (4) I am not the person appointed as Agent or alternate agent by this Power; (5) I am not the Principal’s attending physician, a health care provider who is treating the Principal, or an employee or operator of a health care facility or residential care facility where the Principal is a patient or resident; and (6) I signed in the presence of the Principal.
13.3 Additional statement. At least one of the witnesses further declares that I am not related to the Principal by blood, marriage or adoption, and that to the best of my knowledge I am not entitled to any part of the Principal’s estate on the Principal’s death under a will now existing or by operation of law.
First witness: [First witness: name], of [First witness: address]. Second witness: [Second witness: name], of [Second witness: address].
Signatures
Principal (the person appointing an agent) · First witness · Second witness