Medical Power of Attorney

Who is this Medical Power of Attorney for?

What is the patient's name?

This individual will be known as the "patient" on this document. If you are the patient, enter your name.

What is the patient's mailing address?

Street Address

Address Line 2

City

State

ZIP Code

Who will be making medical decisions for the patient?

This individual will be known as the "agent" on this document.

Agent's phone number

Agent's email address

Do you want to enter the agent's address now?

YesNo, I will enter it later.

Agent's mailing address

Street Address

Address Line 2

City

State

ZIP Code

Does the patient want to appoint an alternate agent?

YesNo

In case the original agent is unavailable or unwilling to make a decision on the patient's behalf.

Name of alternate agent

Phone number

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

Does the patient want to appoint a second alternate agent?

YesNo

In case both the original agent and the first alternate agent are unavailable or unwilling to make a decision on the patient's behalf.

Name of second alternate agent

Phone number

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

Will the agent be granted access to the patient's medical records?

YesNo

In accordance with HIPAA (Health Insurance Portability and Accountability Act) of 1996.

Will there be any limitations to the agent's powers?

Yes, there will be limitations.No, there will not be any limitations.

Without any limitations, the agent may have the power to choose to withdraw life-sustaining care, drinking, and/or feeding.

The agent is authorized to make all healthcare decisions for me, except as I state here:

When will the agent's powers become effective?

Upon incapacitationImmediately

Typically, the agent is granted power upon the patient's incapacitation.

When will the agent's powers be terminated?

Upon the patient's deathOn a specified end date

Most commonly, the agent's powers are terminated upon the patient's death.

Enter the end date:

Will the agent have certain authorities after the patient's death?

YesNo

Related to donating organs, authorizing an autopsy, and the direct disposition of the remains.

Will there be any exceptions to this?

YesNo

List the exceptions:

Does the patient want to add a living will to this medical power of attorney?

YesNo

A living will specifically states the patient's preferences for end-of-life treatment for hospital staff in case their agent is not available.

Does the patient want to prolong their life even if they are determined to be in an irreversible condition or permanently unconscious?

Yes, I want to prolong my life as long as possible.No, I do not want my life prolonged.

If medical staff believe that the patient is in pain, does the patient want to elect to have pain medication be given even if it risks death?

YesNo

Are there any other wishes the patient wants to add to their end-of-life treatment?

YesNo

Add the following medical requests:

Does the patient wish to donate any of their organs after their death?

YesNo

Which parts of the body may be donated?

All parts of the bodyOnly specified organs

List the following body parts that may be used for organ donation:

The patient's organs may be used for:

TransplantTherapyResearchEducation

Does the patient want to enter their primary care physician's information?

YesNo

Physician's name

Phone number

Office address

Street Address

Address Line 2

City

State

ZIP Code

Where will copies of this medical power of attorney will be held?

The patient is a resident of

Under state law, the patient is required to sign this document in the presence of two witnesses.

I understand.

The two witnesses cannot be related by blood, be a beneficiary of the patient's estate, or be medical staff.

Under Arizona law, the patient is required to sign in the presence of one witness or a notary public.

I understand.

If the patient decides to sign in front of a witness, the witness cannot be blood-related, medical staff, or a beneficiary in the patient's will.

Under Utah law, the patient is required to sign in the presence of one witness.

I understand.

The witness can be a notary public but cannot be a person who is blood-related, a beneficiary in the patient's will, or medical staff.

Under state law, the patient is required to sign with either two witnesses or a notary public.

I understand.

If the patient decides to sign with two witnesses, they cannot be blood-related, a beneficiary in the patient's will, or medical staff.

Under state law, the patient is required to sign with two witnesses and a notary public.

I understand.

Under state law, the patient is only required to sign. However, it is recommended to sign in the presence of a notary public.

I understand.

If the document is notarized, no third party will be able to claim that the patient did not sign out of their own free will. A notarization legitimizes any document as being signed by the actual signer.

Connecticut Medical Power of Attorney