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Colorado Medical Durable Power of Attorney Form

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The Colorado Medical Durable power of attorney gives you the ability to appoint someone as an agent for medical care and decisions if you find yourself in a position where you are unconscious or mentally incompetent. Your agent will be able to access your medical records, speak to your healthcare professionals and make decisions. It is important that you choose someone you have faith will carry out your wishes and that you explain your wishes to them, as well as outlining them on this form to the best of your ability.

LawsSections 15-14-503 to 15-14-509 (Colorado Patient Autonomy Act)

Living Will – Use to disqualify options for treatment at the end of someone’s life if he or she is incapacitated with no options to cure by doctors.

Durable (Financial) Power of Attorney – Complete this form to designate a trusted individual to take care of your finances and property when unavailable or unable to do so yourself.

How to Write

1 – Organize The Paperwork

Download or Open this form using the buttons below the file image preview. Make sure you have double checked all the information that must be reported as being up-to-date and accurate.

2 – I. Appointment of Agent and Alternatives

The first section will require the Name and Contact Information of the Agents being granted power. To begin, identify the Principal granting this power on the first blank line in Section I.

The second blank line must have the Full Name of the individual being granted the power to make Medical Decisions on behalf of the Principal for the Principal at the discretion of the Principal.

The next empty line, titled “Agent’s Best Contact Telephone Number,” will require a well-maintained Telephone Number where the Agent can be reached fairly quickly.

The line below this, “Agent’s Email or Alternative Telephone Number,” requires that an alternate method of contact for the Agent be defined. This may be a second Phone Number or an Email Address.

The next line, “Agent’s home address,” must present the Agent’s Residential Address.

Read the text provided as this will contain some of the actions the Agent may take. Below this will be enough room to report two Alternate Agents. Starting with the first line, report the “Name of Alternate Agent,” the Alternate Agent’s “Best Contact Telephone Number,” a secondary form of Contact such as an Alternate Number or Email, and the Alternate Agent’s home Address (in that order).

The next section is reserved for a second Alternate Agent in case neither the Primary nor First Alternate Agent is able to live up to the responsibility of the Agent role described in this document. Here, you should enter the second Alternate Agent’s Full Name, Primary Contact Number, Alternate Number or Email Address, and Home Address.

 

3 – II. When Agent’s Powers Begin

The second section will require the Principal initial one of the choices presented. If this Authority will go into Effect upon Signing, the Principal will need to initial the first statement.

If this Authority will only go into Effect when a Physician declares the Principal unable to make or express his or her preferences, the Principal will need to initial the second statement.

4 – III. Instructions To Agent

The next area will contain several blank lines. Generally, the Agent will need to be fully aware of the instructions, preferences, and restrictions concerning the Principal’s Health Care, especially in particularly damaging life events (i.e. coma). The Principal should very specifically outline his or her wishes. Subjects addressed should include such aspects as Emergency Medical Care, Medical Intervention of End-of-Life events, Treatment regarding long-term and/or terminal care, etc. If there are any questions as to what the Principal may or may not request, then it is strongly recommended to consult an experienced professional on this matter before continuing.

5 – Signature of Declarant

Locate the statement beginning with the words “My signature below…” The Principal must Sign the blank line below this statement and enter the Date he or she signed this document.

6 – Addendum To Medical Durable Power of Attorney

The next page will contain several areas that, while not required, are generally recommended. The Agent will be required to provide some items as well as two witnesses and a notary. Locate “1. Signature of the Appointed Agent.” This will contain a statement acknowledging the acceptance of authority from the Principal by the Appointed Agent. The first space (in the introduction paragraph) will require the Name of the Principal or Declarant as it is recorded above.

Below the required wording will be an area for the Primary Agent, Alternate Agent #1, and Alternate Agent #2 to provide their Signatures. Each one will have his or her own clearly labeled section and each section will require the same information as the other two. Each Agent must sign his or her Name on the first line of their respective area. Then, on the second line, the Agent must print his or her name. The Agent must provide the Date of Signature on the third line. If any Alternate Agent’s have been designated by the Principal, then make sure the same items have been provided by Alternate Agent #1 and Alternate Agent #2.

Locate “2. Signature of Witnesses and Notary.” This section will provide an area for two Witnesses and a Notary to verify they have viewed the signing. On the first blank space, below the words “This document was signed by…,” enter the name of the Principal.

Each Witness will have his or her own set of blank lines to be attended to. The first blank line, “Signature of Witness,” requires the Witness to sign his or her Name at the time of the Principal Signing. The second blank line must have the Printed Name of the Signature Witness presented. The third blank line requires the Address of the Signature Witness to be entered.

The final area, “Notary Seal,” requires items only a Notary Public may supply.

 


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