MEDICAL POWER OF ATTORNEY

1. APPOINTMENT OF HEALTH CARE AGENT

I, [PRINCIPAL NAME] of [ADDRESS], City of [CITY], State of [STATE] (HEREINAFTER known as the “Principal”) hereby appoint, [AGENT NAME] of [ADDRESS], City of [CITY], State of [STATE] (HEREINAFTER known as the “Agent”) as my Agent to make any and all medical decisions on my behalf, except to the extent I limit those decisions in this document. This power of attorney takes effect if my doctor certifies in writing that I can no longer make my own health care decisions. My agent can be reached at the following contact information:

Home Phone:[PHONE] Work Phone: [PHONE]

Cell Phone: [PHONE] E-Mail: [EMAIL]

2. LIMITATIONS OF MY AGENT

My agent is authorized to make all medical decisions on my behalf EXCEPT for the following: [LIST LIMITATIONS]

3. APPOINTMENT OF ALTERNATE AGENT

If my agent appointed above is unable or unwilling to serve as my agent, I appoint the following person(s) to serve as agents in the order set forth below with the authority to make health care decisions on my behalf as provided herein:

a. First Alternate Agent

Name: [NAME] Address: [ADDRESS] Phone: [PHONE]

b. Second Alternate Agent

Name: [NAME] Address: [ADDRESS] Phone: [PHONE]

4. ORIGINAL AND COPIES OF THIS DOCUMENT

The original document is/will be filed in the following place: [LOCATION]

I have/will provide copies of my medical power of attorney to the following: [NAME(S)]

5. DURATION

Unless stated otherwise herein, this document shall remain in effect until I revoke it. I understand that I cannot revoke this document during the time I am considered incompetent to make my own decisions.

(If applicable Initial and Check)

________ ☐  (OPTIONAL) This power of attorney shall expire on [DAY] of [MONTH], [YEAR].

6. PRIOR MEDICAL POWER OF ATTORNEY

By signing this document, I hereby revoke any and all prior medical powers of attorney that I may have executed.

7. EXECUTION

(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY. YOU MAY SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED BEFORE A NOTARY PUBLIC

OR

YOU MAY SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT WITNESSES NOT RELATED BY BLOOD OR MARRIAGE.)

SIGNATURES

I /We hereby execute this document on [DAY] of [MONTH], [YEAR] in the City of [CITY], State of [STATE].

Principal’s Signature: _____________________          Print Name: ______________________

Agent’s Signature: _____________________               Print Name: ______________________

1^st Alt. Agent’s Signature: ____________________    Print Name: ______________________

2^nd Alt. Agent’s Signature: ____________________  Print Name: ______________________

NOTARY ACKNOWLEDGMENT

STATE OF [STATE]

[COUNTY] County, ss.

On this [DAY] of [MONTH], [YEAR], before me appeared [NAME], as Maker of this Medical Power of Attorney who proved to me through government-issued photo identification to be the above-named person, in my presence executed foregoing instrument and acknowledged that (s)he executed the same as his/her free act and deed.

Notary Public: _____________________

Print Name: _____________________

My commission expires: _____________________

(seal)

WITNESS STATEMENT AND ACKNOWLEDGMENT

I am not the person appointed as agent or successor agent in this medical power of attorney. I am not related to the maker of this document by blood or marriage. I am not entitled to any portion of the maker’s estate, nor do I have any claim against the maker’s estate. I am not the attending physician of the maker or an employee of the attending physician. I am not involved in providing direct patient care to the maker and am not an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility.

SIGNATURE OF FIRST WITNESS

Signature: ________________________________________________

Print Name: ___________________________________ Date: __________

Address: __________________________________________________

SIGNATURE OF SECOND WITNESS

Signature: ________________________________________________

Print Name: ___________________________________ Date: __________

Address: __________________________________________________