Healthcare Power of Attorney Form
Healthcare Power of Attorney Form
Please complete this form to designate an individual who will make medical decisions on your behalf if you become unable to do so.
Principal (Person Granting Authority):
I,
Address
Phone number
Date of Birth
Hereby designate the person named below as my agent to make healthcare decisions on my behalf:
Agent Name
Relationship
Phone number
If the agent is unavailable or unable to act, I appoint the following alternate agent:
Alternate Agent's Full Name
Relationship to Principal
3. Grant of Authority:
My agent has the full authority to make healthcare decisions for me, including but not limited to:
-
Consent to, refuse, or withdraw consent to any medical care, treatment, service, or procedure.
-
Make decisions about my care, including hospitalization, surgery, medication, and life-sustaining treatment.
-
Access my medical records and discuss my health with my healthcare providers.
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Arrange for my admission to or discharge from any medical facility, including nursing homes or hospice care.
This power is effective immediately and shall remain in effect unless revoked by me in writing.
I, the principal, sign my name to this Healthcare Power of Attorney on
Principal’s Signature:
Date:
Witness 1:
Full Name:
Signature:
State of
On
Notary Public’s Signature Principal
My commission expires:
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