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Colorado Medical Power of Attorney Form

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A Colorado medical power of attorney gives a person the ability to appoint someone as an agent for medical care decisions if they should find themselves unconscious or mentally incompetent. The agent will be able to access medical records, speak to healthcare professionals, and be able to make decisions. It is common for a spouse or family member to be the agent. Most importantly, the agent should be someone who is always reachable in the event of an emergency.

Laws§ 15-14-506

Signing Requirements – Only the principal is required to sign. Although, it’s recommended a 3rd party witness the principal’s signature such as a family member or notary public.

State Definition (§ 15-14-500.5(1)(a)) – For purposes of sections 15-14-501 and 15-14-502, “power of attorney” means a power to make health care decisions granted by an individual.

How to Write

Download: Adobe PDF

Step 1 – Access The Medical Durable Power Of Attorney 

The Colorado Medical Durable Power Of Attorney For Healthcare Decisions is obtainable from this site as a “PDF” document. You may save it directly to an accessible folder in your system or on your machine by selecting the “PDF” button or the “Adobe PDF” link in this area (above).

Step 2 – Identify Yourself As The Colorado Principal

Open this form once you have determined the identity of your Health Care Agents and what your end-of-life preferences are in relevant scenarios where your medical health is at risk. The titled area in the upper left-hand corner of the first page, “I. Appointment Of Agent And Alternates” will open this directive with several requests for information. The first requirement will be that an entry of the Principal or Declarant’s name is produced on the first available blank line. This is the Party that will grant an Agent the authority to represent his or her interests during a medical event. If you are the Principal holding authority and appointing an Agent, then produce your name on this line. 

 

Step 3 – Name The Colorado Agent Being Named With Health Care Powers

The line labeled “Name Of Agent” seeks the full name of the individual you wish to act as your Health Care Representative or Agent. The Party named on this line shall act with the authority you define through this directive when a medical event has rendered you unable to communicate. It is worth noting that other power of attorney forms will commonly call such an Agent the Attorney-in-Fact.

 

Step 4 – Dispense The Home, Business, Or Agent Cell Number

A few pieces of information will be required to define the Health Care Agent’s identity. The second blank line indicates that a presentation of the “Agent’s Best Contact Telephone Number” is furnished. Due to the nature of this paperwork, it is important that your Health Care Agent can be reached in an expedient and reliable manner. 

 

Step 5 – Furnish An Additional Means Of Contact

Continue to the next available blank line where the label “Agent’s Email Or Alternative Telephone Number” calls for another means of contact the Health Care Agent monitors regularly. As mentioned earlier, the Health Care Agent or Representative you are appointing must be reachable through the information in this area.  

 

Step 6 – Include The Agent’s Contact Address

Finally, the “Agent’s Home Address” should be documented. This must be the address where the appointed Health Care Agent can be physically found. Make sure to report this information accurately since it may be used for important correspondence where a signature approval is required for treatment. 

 

Step 7 – Appoint An Alternate Agent As A Security Measure

As discussed, it will be important for you to have a Health Care Representative to handle questions and decisions regarding your health care or treatment if or when you are incapacitated or otherwise unable to communicate. Thus, if the Health Care Agent or Representative you have named above cannot be reached then a back-up Agent can be named here to step into this role. This can be thought of as a wise precaution. The Alternate Agent will not have any representative powers until (or unless) the Health Care Agent you appointed above is unavailable, steps down, or has been revoked. Once this occurs, the same principal powers you grant to him or her will be transferred to the Alternate Agent. To appoint an Alternate Health Care Agent, document his or her full name on the blank line labeled “Name Of Alternate Agent #1.”   

 

Step 8 – Furnish A Reliable Method To Contact The Alternate Agent

As with the appointed Health Care Agent, the Alternate Health Care “Agent’s Best Contact Telephone Number” should be displayed with his or her name. Proceed to the second blank line in this area to document this information properly. 

 

Step 9 – Deliver A Second Option To Utilize When Contacting The Alternate Agent

The Alternate “Agent’s Email Or Alternative Telephone Number” should also be produced for display. Bear in mind, this back-up information will be requested as a means of contacting the Alternate Agent when all the above efforts to obtain a medical decision on your behalf have failed. Thus, make sure the entry furnished here is up-to-date and accurate.

 

Step 10 – Submit The Alternate Agent’s Current Home Address

The next line requiring a report is “Agent’s Home Address” and this should be supplied with the Alternate Health Care Agent’s physical address. 

 

Step 11 – Designate A Second Alternate Agent

In addition to the Health Care Agent and the Primary Health Care Agent, you may also appoint an Alternate Health Care Agent. It should be noted that, like the First Alternate Agent, the Second Alternate Agent will only be granted principal power if neither of the previous Agents has the will or ability to represent the Principal (You). Generally, this considered a precautionary measure that should be employed for the sake of the safety of making sure you have an Attorney-in-Fact or Health Care Agent to safeguard your medical preferences in place at all times. The “Name Of Alternate Agent #2″ line can be used to appoint this Second Alternate Health Care Agent should the previous ones (the appointed Health Care Agent and Alternate Health Care Agent”) be unable to act in their assigned role. 

 

Step 12 – Present The Second Alternate Agent’s Current Telephone Number

The next line down will seek the Second Alternate “Agent’s Best Contact Telephone Number” reported.

 

Step 13 – Report The Second Alternate Agent’s Additional Means Of Contact

A continuation of this section will require the Second Alternate “Agent’s Email Or Alternative Telephone Number” furnished for reference. 

 

Step 14 – Record The Address Of The Second Alternate Health Care Agent

Lastly, the Second Alternate “Agent’s Home Address” will be required for display on the final blank line of the first column area. 

 

Step 15 – Define When Your Principal Authority Can Be Used By Your Agent

Continue to the top of the second column on the first page. The article titled “II. When Agent’s Powers Begin” will allow you to indicate when you wish your Health Care Agent to have the authority to represent your interests regarding medical treatment. Two statements defining when this document delivers such power to your Health Care Agent have been placed on display with a blank line preceding each one. You, as the Principal, must initial one of these to indicate when you wish the health care representational powers being delivered become effective or active. If the Health Care Agent may begin wielding authority to carry out your instructions as soon as you execute this form, then initial the blank line attached to the words “Immediately Upon My Signature.”  If the principal authority you define in this paperwork will only be at the Health Care Agent’s disposal when qualified Medical Professionals declare you officially unable to communicate effectively, then initial the second blank line. 

 

Step 16 – Document Your Medical Preferences And Health Care Directives 

The third section enables a direct report defining your preferences regarding health care, treatment, and any relevant scenario that you wish to retain control over (even when unconscious). It should be mentioned however that the “III. Instructions To Agent” section will be understood to be the result of a discussion between the Health Care Agent and yourself as well as the result of a medical consultation on the matter(s). Use the blank lines in this section to describe your directives regarding topics such as “Life-Sustaining Procedures, Treatment, General Care And Services” as well as any limitations, restrictions, conditions, and specific instructions. While quite a bit of space has been supplied, you may continue with a well-labeled attachment should you require more room for a complete report of your medical directives and instructions. 

 

Step 17 – Formally Execute The Designation Of Your Medical Attorney-in-Fact 

The last blank space on this page presents two labels on either side “Signature Of Declarant” and “Date.” Once you have properly appointed your Health Care Agent(s) and specified your medical preferences, you must sign the area labeled “Signature Of Declarant” then produce the current “Date” across from it. If this is done before a Witness, release this signed paperwork to this party and instruct him or her to tender their signature after reviewing it. If a Notary is employed, then follow his or her directions for this signing.

 

Step 18 – Include Additional Signature Parties At Your Discretion

The “Addendum To Medical Durable Power Of Attorney – Recommended, Not Required” allows for a continuation of proving the authenticity of this paperwork. The State of Colorado will not require these items however other states will and some municipalities may differ. Thus, record your name as the Principal or Declarant on the first blank line in “1. Signature Of The Appointed Agent,” then release this document to the Health Care Agent(s) you selected. 

 

Step 19 – Set Up The Health Care Agent Acknowledgment Area

The Primary Health Care Agent (the first one appointed with principal authority) should read this entire document and the attached addendum. If the Primary Health Care Agent agrees to the responsibility his or her role places, then the “Primary Agent’s Signature” line must be signed by the Medical Attorney-in-Fact you chose as your Primary Health Care Agent.

 

Step 20 – Obtain The Signature Of The Health Care Agents 

The next blank line should be furnished with the Primary Health Care Agent’s “Printed Name”   Finally, the Primary Health Care Agent must record the current “Date” of his or her signature. If other Parties are due to review and sign this document then, it should be released to their control. If an Alternate Health Care Agent has been named, then this individual must perform the same review the Primary Health Care Agent completed and sign his or her name on the “Alternate Agent # 1” line. Additionally, the Alternate Health Care Agent must proceed to the next line down to supply his or her “Printed Name.” The “Date” when the Alternate Health Care Agent signed this paperwork must now be entered. Only the signature party this “Date” refers to may satisfy the next line down. If a Second Alternate Agent has been named, then this paperwork must now go to him or her. If not, then it should be released to the Witness or Notary in attendance. If you have appointed a Second Alternate Agent, then he or she must be given the opportunity to review this paperwork. Upon completion of this task, the Second Alternate Agent should sign the “Alternate Agent #2 Signature” line. The Second Alternate Agent must also print his or her full name on the next line down.  Finally, the Second Alternate Agent signing this paperwork must attach the current date to his or her signature on the line labeled “Date.” Once these tasks are completed, this paperwork may be released to the appropriate Party (the Principal, Witnesses, a Notary Public).   

 

Step 21 – Prepare To Prove The Authenticity To The Principal Act Of Signing

The second column of the addendum is devoted to providing authenticity for the provided signatures (including your own). Before this paperwork is released to the Signature Witness(es) and/or Notary Public observing this directive’s execution, make sure the full name of the Principal or Declarant is produced on the blank line immediately following the parentheses label “Name Of Declarant” in the section titled “2. Signature Of Witnesses And Notary.” 

 

Step 22 – Use The Witness Testimonial To Validate The Principal Signing

If the Principal and Agent signings are to be verified by one or more Witnesses, then testimony to the observation of the signing must take place. The First Signature Witness must read the paragraph in “2. Signature Of Witnesses And Notary” then sign his or her name on the first “Signature Of Witness’ line.  After producing his or her signature, the First Witness must, then, print his or her name as the content of the “Printed Name” line that follows.  Since it may be important to reach this Party for direct confirmation of this document’s authenticity, his or her address must also be supplied. The “Address” line provided will act as a display area for this information. The Second Witness attesting to the validity of this directive’s executing Parties should read the “2. Signature Of Witnesses And Notary” section then sign the second “Signature Of Witness”  After supplying the requested signature, the Second Witness must proceed one line down where the “Printed Name” of his or her signature must be entered.

The Second Witness must also be reachable by mail. Thus, the Second Alternate Health Care Agent must produce his or her address for display on the second “Address” line in this section. 

 

Step 23 – Notarize The Principal’s Execution Of This Document To Show Its Authenticity

If this directive is to be notarized, then the Notary Public will have issued instructions on how the signing is to occur. Follow them, then review the “Notary Seal” section after the full execution process has been completed. The Notary Public should have verified the location of the signing as well as the signature parties in attendance. Additionally, the Notary will provide documentation as to the date of the signing before producing his or her credentials.

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Advance Directive

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Durable Financial Power of Attorney

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