Free Medical Power of Attorney Template
Medical Power of Attorney
I. Appointment of Healthcare Proxy
I, [Your Name], residing at [Your Company Address], hereby appoint Amelia Pagac, residing at Tampa, FL 33601, as my healthcare proxy to make healthcare decisions on my behalf in the event that I am unable to do so myself due to incapacity or incompetence.
II. Scope of Authority
My healthcare proxy shall have the authority to make decisions regarding my medical treatment, including but not limited to:
-
Consent to or refuse medical treatment, surgery, or procedures.
-
Access my medical records and communicate with healthcare providers.
-
Make decisions about medication and treatment options.
-
Choose healthcare facilities and providers for my care.
-
Make end-of-life choices, including stopping life-sustaining treatment.
III. Duties and Responsibilities
-
Decision Making: The healthcare proxy shall exercise their authority with diligence and in accordance with my wishes, as expressed in this document or otherwise communicated to them.
-
Consultation with Medical Professionals: They shall consult with medical professionals and consider medical advice when making decisions on my behalf.
-
Records Keeping: The healthcare proxy shall keep accurate records of any decisions made and actions taken on my behalf.
-
Reporting and Communication: They shall provide updates to my designated family members or other individuals involved in my care upon request or as necessary.
-
Compliance with Legal Requirements: The healthcare proxy shall comply with all applicable laws and regulations governing healthcare decision-making.
IV. Termination of Authority
This Power of Attorney for Healthcare shall remain in effect unless revoked by me in writing or upon my death. In the event of revocation, notification shall be provided to my healthcare proxy and any relevant healthcare providers. Upon termination, the healthcare proxy's authority shall cease immediately, and any copies of this document shall be returned to the Principal or destroyed.
V. Remedy or Penalty Clauses
In the event that my healthcare proxy fails to fulfill their duties or acts in a manner contrary to my best interests, they shall be subject to immediate revocation of this Power of Attorney for Healthcare. Additionally, they may be held liable for any damages resulting from their actions or decisions. Furthermore, the Principal reserves the right to pursue legal remedies available under the law for any breach of fiduciary duty by the healthcare proxy.
VI. Governing Law
This Power of Attorney for Healthcare shall be governed by the laws of the state of Illinois, without regard to conflicts of laws principles. Any disputes arising under or related to this document shall be resolved in the courts of Illinois.
VII. Severability
If any provision of this Power of Attorney for Healthcare is held to be invalid or unenforceable, such provision shall be severed from the remainder of this document, which shall remain in full force and effect. The invalidity or unenforceability of any provision shall not affect the validity or enforceability of the remaining provisions of this document.
IN WITNESS WHEREOF, I have executed this Power of Attorney for Healthcare on August 20, 2050.
Principal: [Your Name]
Agent: Amelia Pagac
VIII. Witness Acknowledgement
We, the undersigned witnesses, hereby acknowledge that the above-named Principal has signed this Power of Attorney for Healthcare in our presence on the date stated above.
Jasen Gaylord
August 20, 2050
Jake Willms
August 20, 2050
IX. Notary Acknowledgement
On this 20th day of August in the year 2050, before me, a Notary Public in and for said County and State, personally appeared [Your Name], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that they executed the same for the purposes therein contained.
Witness my hand and official seal.
Notary Public's Name: Maxwell Mante
My Commission Expires: August 20, 2055
