Free Health Directive Power of Attorney Form Template
Health Directive Power of Attorney Form
Please complete this form to designate an individual to make healthcare decisions.
Principal Information
Name
Date of Birth
Address
Phone Number
Agent Information
Name
Relationship to Principal
Address
Phone Number
Scope of Authority
I hereby appoint the above agent to make healthcare decisions on my behalf, including but not limited to:
-
Consenting to or refusing medical treatments
-
Admitting or discharging me from healthcare facilities
-
Accessing my medical records
-
Communicating with healthcare providers about my care
-
Making decisions about end-of-life care consistent with my wishes
-
Limitations or Special Instructions
Signatures
By signing below, I declare that I understand the purpose of this document and that I am authorizing the named individual to make healthcare decisions on my behalf. I affirm that this document reflects my wishes.
|
Principal
Name: Date: |
Witness
Name: Date: |
Power of Attorney Form Templates @ Template.net
Thank you for your submission!
We appreciate you taking the time to submit.
Create free forms at Template.net
