Who is this Medical Power of Attorney for? Who is this Medical Power of Attorney for? MyselfMy childMy spouse or partnerMy parent or relativeSomeone else 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 Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming 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? 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 Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Does the patient want to appoint an alternate agent? 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 Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Does the patient want to appoint a second alternate agent? 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 Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Will the agent be granted access to the patient's medical records? 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? 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? 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? 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? 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? 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? 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? 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? 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? 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? Does the patient wish to donate any of their organs after their death? YesNo Which parts of the body may be donated? 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: The patient's organs may be used for: TransplantTherapyResearchEducation Does the patient want to enter their primary care physician's information? 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 Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Where will copies of this medical power of attorney will be held? The patient is a resident of Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming Under state law, the patient is required to sign this document in the presence of two witnesses. 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. 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. 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. 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. 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. 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. Next Save Save and finish later
