Free Medical Power of Attorney Form Template
Medical Power of Attorney Form
Introduction
This Medical Power of Attorney is made and entered into on
Alternate Agent Information
If the primary agent is unable or unwilling to act on my behalf, I appoint:
Name
Address
Scope of Authority
I authorize my agent to make healthcare decisions for me, including but not limited to consenting to or refusing medical treatment, accessing my medical records, and determining my care plan if I am unable to communicate or make these decisions myself.
Effective Date and Duration
This power of attorney becomes effective immediately upon my incapacity and remains in effect until I regain the capacity to make medical decisions or until I revoke this authority in writing.
Signature
By signing below, I acknowledge that I have read, understood, and voluntarily signed this Medical Power of Attorney, and I am fully aware of its implications.
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Principal
Name: Date: |
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Witness 1
Name: Date: |
Witness 2
Name: Date: |
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