Free Healthcare Surrogate Power of Attorney Form Template
Healthcare Surrogate Power of Attorney Form
Please fill out this form to appoint a healthcare surrogate.
Declarant Information
Name
Date of Birth
Address
Phone Number
Healthcare Surrogate Information
Name
Relationship to Declarant
Address
Phone Number
Authority Granted
Select all that apply:
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Accessing my medical records
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Providing informed consent for medical treatments
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Making decisions about life-sustaining treatment
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Communicating with healthcare providers on my behalf
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Special Instructions
Signatures
By signing below, I affirm that I am of sound mind and executing this document voluntarily. This authority will become effective only if I am unable to make my own healthcare decisions. This designation remains in effect until revoked in writing or replaced by a new form.
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Declarant
Name: Date: |
Witness
Name: Date: |
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