Free Professional Durable Medical Power of Attorney Template
PROFESSIONAL DURABLE MEDICAL POWER OF ATTORNEY
I. INTRODUCTION
This Professional Durable Medical Power of Attorney for Healthcare is made on the 20th day of August 2050. I, [Your Name], residing at [Your Company Address], being of sound mind, hereby designate John Smith, residing at 123 Elm Street, Springfield, IL 62704, as my appointed agent to make medical decisions on my behalf in the event that I become unable to communicate due to a severe illness or incapacitation.
II. DESIGNATION OF HEALTHCARE AGENT
I hereby appoint John Smith as my healthcare agent (hereinafter referred to as "agent"). In the event that John Smith is unable, unwilling, or unavailable to act as my agent, I designate Mary Johnson, residing at 456 Oak Avenue, Springfield, IL 62705, as my successor agent to serve with the full authority granted herein.
III. GRANT OF AUTHORITY
My agent shall have the authority to make any and all medical and healthcare decisions for me, including but not limited to:
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Medical Treatment: Consenting to, refusing, or withdrawing consent to any medical treatment, surgery, or procedure.
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Healthcare Institutions: Making decisions concerning my admission to or discharge from hospitals, nursing homes, residential care, assisted living facilities, or other healthcare institutions.
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Health Information: I need to access my personal health information and communicate with my healthcare providers in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
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Medical Records: Authorizing the release of my medical records to third parties as deemed necessary for my healthcare.
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Health Treatment: Making decisions regarding physical and mental health treatment, including the use of life support systems and palliative care.
IV. LIMITATIONS OF AUTHORITY
The authority of my agent is subject to the following limitations:
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Preference Compliance: My agent is not authorized to consent to any act or omission to which I have previously expressed a contrary preference in a written or oral declaration.
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Artificial Nutrition and Hydration: My agent shall not have the authority to authorize the withholding or withdrawal of artificial nutrition and hydration unless it is clear that this action aligns with my previously expressed wishes or is in my best interests.
V. DURATION OF AUTHORITY
The authority granted to my agent shall become effective upon my attending physician’s determination that I am incapacitated and unable to make my own medical decisions. This authority shall remain in effect until my attending physician determines that I am capable of making my own medical decisions or until my death.
VI. REVOCATION
I reserve the right to revoke this Power of Attorney for Healthcare at any time and for any reason, provided that I am mentally competent to do so. Such revocation must be communicated in writing and delivered to my healthcare agent and any attending physicians or healthcare providers.
VII. ACCEPTANCE OF APPOINTMENT
By signing below, John Smith acknowledges acceptance of the appointment as my healthcare agent and agrees to act in accordance with the terms set forth in this document.
VIII. SIGNATURES
Principal’s Signature
Date: August 20, 2050
Agent’s Signature
Date: August 20, 2050
Witness Signature
Date: August 20, 2050
IX. NOTARIZATION
State of Illinois
On this 20th day of August 2050, before me, the undersigned Notary Public personally appeared [Your Name] and John Smith, known to me (or satisfactorily proven) to be the persons whose names are subscribed within this Power of Attorney for Healthcare document, and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I have hereunto set my hand and official seal.
Notary Public Signature: Robert Davis
My Commission Expires: August 20, 2055
