Free Medical Power of Attorney Form Template
Name someone you trust to make healthcare decisions for you if you cannot speak for yourself. This printable medical power of attorney appoints a healthcare agent and alternate, states your wishes about life-sustaining treatment, and grants access to your medical records. Fill in your choices and print a copy ready for signing and witnessing.
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MEDICAL POWER OF ATTORNEY
This Medical Power of Attorney is made on ________________ by ________________ ("Principal"), of ________________.
1. DESIGNATION OF HEALTHCARE AGENT. The Principal appoints ________________, of ________________, phone ________________, as the Principal's healthcare agent (the "Agent") to make healthcare decisions for the Principal.
2. ALTERNATE AGENT. If the Agent is unavailable, unable, or unwilling to serve, the Principal appoints ________________, phone ________________, to serve as alternate Agent with the same authority.
3. WHEN AUTHORITY BECOMES EFFECTIVE. The Agent's authority to make healthcare decisions takes effect when the Principal's attending physician determines that the Principal lacks the capacity to make or communicate healthcare decisions. The authority ends if the Principal regains capacity.
4. AUTHORITY OF AGENT. The Agent may make any healthcare decision the Principal could make, including consenting to or refusing treatment, choosing healthcare providers and facilities, and making decisions about diagnosis, care, and services, consistent with the Principal's wishes stated below.
5. LIFE-SUSTAINING TREATMENT. Regarding treatment that would serve only to prolong the dying process, the Principal directs as follows: ________________.
6. OTHER WISHES AND INSTRUCTIONS. The Principal provides the following additional guidance: ________________.
7. ACCESS TO MEDICAL RECORDS. ________________ This authorization applies to information governed by the Health Insurance Portability and Accountability Act (HIPAA) and related regulations, so that the Agent can make informed decisions.
8. DUTY OF THE AGENT. The Agent shall act in good faith and in accordance with the Principal's known wishes and best interest. Where the Principal's wishes are not known, the Agent shall act in the Principal's best interest, considering the Principal's values.
9. REVOCATION. The Principal may revoke this Medical Power of Attorney at any time and in any manner that communicates an intent to revoke, including by notifying the Agent or a healthcare provider. This document revokes any prior medical power of attorney.
10. GOVERNING LAW. This Medical Power of Attorney is governed by the laws of the State of ________________. If any provision is found unenforceable, the remaining provisions stay in full effect.
This is a general template and not legal advice. Requirements for advance directives and healthcare proxies, including who may witness the document, notarization, and the wording that controls life-sustaining treatment, vary by state. Review your state's requirements or have an attorney or your healthcare provider review this document before use.
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These are professionally structured templates using standard clause language. Whether a completed document is legally binding depends on your state's requirements, proper signing (and notarization or witnesses where required), and your specific situation. For anything high-stakes, have an attorney review it. Nothing here is legal advice.
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The template includes signature lines. Some documents need witnesses or a notary to be enforceable in your state. Check your state's requirements before signing, and use a notary where one is required.