eForms Logo

North Carolina Medical Power of Attorney Form

Create a high-quality document now!

North Carolina Medical Power of Attorney Form

Updated August 09, 2023

A North Carolina medical power of attorney is a statutory form that allows a principal to appoint another person to make medical decisions on their behalf. This power only becomes available when the principal is no longer able to make health care decisions for themselves (i.e. incapacitated).


How to Write

Download: PDF, MS Word, OpenDocument

1 – The Paperwork Here Can Be Used To Appoint A Health Care Agent

Locate the three buttons below the image and select any one of them to download the file type you prefer working with. Make sure you have all the reference material required when filling out this template as all the requested information must be presented accurately

2 – The Health Care Agent Must Be Officially Named By The Principal

The individual who intends to appoint a Health Care Agent with the Authority to make Health Care Decisions on his or her behalf is referred to as the Principal. Record this party’s Legal Name on the first blank line in the first article (“1. Designation Of Health Care Agent”)

The Principal statement will contain the language necessary to appoint a Health Care Agent, however, the Identity and Contact Information of the Health Care Agent will need to be disclosed for this article to be complete. Enough room has been provided so that up to three Health Care Agents may be delegated with the Authority to handle Medical Decisions on behalf of the Principal. If more than one Health Care Agent is being designated here, list them in the order of who should be contacted first to who should be contacted last. Each area (“A,” “B,” and “C”) will supply a blank line with the labels “Name,” “Home Address,” “Home Telephone,” “Work Telephone,” and “Cellular Telephone.” Each Agent declared must have his or her Full Legal Name, Home Address, and at least one current Telephone Number where they can be reliably reached (immediately) recorded on these lines.

3 – Present The Physicians Who Can Deliver Principal Status

The second article, “2. Effectiveness Of Appointment,” shall provide two blank lines so that two Physicians can be identified. Each Physician listed will have Authority declaring the Principal as incapacitated and unable to make his or her own Medical Decision, thus placing this document in Effect.

4 – Indicate If Any Restrictions On The Health Care Agent’s Principal Authority Should Apply

Articles three and four should be reviewed thoroughly. While the Principal has the final say in what is and is not included in this appointment, altering either of these articles should only be done upon the suggestion of a legally qualified professional such as a Physician or an Attorney.

The next article requiring attention is the fifth article, “5. Special Provisions And Limitations.” In this section a table will be provided consisting of items A through E. Each item letter will correspond to either Principal Directives or Restrictions meant to apply to the Health Care Agent and/or the Principal Powers appointed to him or her. The Principal must initial any statement that applies then satisfy its requirements

Locate the item labeled “A. Limitations About Artificial Nutrition Or Hydration.” The Principal will need to determine how the Health Care Agent should behave in a scenario where his or her survival depends upon receiving food and water intravenously. If the Health Care Agent should retain the Power to either approve or deny Artificial Nutrition meant for the Principal on behalf of the Principal, then leave this area blank. If the Principal wishes to impose restrictions upon the Health Care Agent’s ability to withhold Artificial Nutrition from the Principal, then he or she must initial the blank line next to the statement “Shall Not Have The Authority To Withhold Artificial Nutrition…” Then record the circumstances upon which the Health Care Agent may utilize the Principal Authority to withhold Artificial Nutrition in the area supplied below this statement after it is initialed.

If the Principal wishes to restrict the Power to decide whether the Health Care Agent may decide upon Artificial Hydration from the Health Care Agent, the Principal will need to initial the blank line next to the statement “Shall Not Have The Authority To Withhold Artificial Hydration…” The Principal may also provide specific scenarios when the Health Care Agent should deny him or her of Artificial Hydration by recording them in the area below this statement.

The Principal declaring this appointment can place provisions upon the Health Care Agent’s use of Principal Power by initialing the blank line corresponding to “B. Limitation Concerning Health Care Decisions.” If this line is initialed the area below the paragraph statement here should have the Principal’s concerns or instructions the Health Care Agent must comply with when making Health Care Decisions regarding the Principal’s care on his or her behalf.

The next topic of Health Care the Principal may address is titled “C. Limitations Concerning Mental Health Care Decisions.” Here, the Principal can report his or her preferences, directives, limitations, or restrictions when the Health Care Agent must make decisions and take actions on behalf of the Principal’s Mental Health Care. If the Principal has any such provisions to apply to this subject, then he or she should initial the blank line to the left of this statement’s label then, record all such instructions in the blank row below this paragraph statement.

In the paragraph statement labeled “D. Advance Instruction For Mental Health Treatment,” the Principal can address the subject of any Advance Instruction For Mental Health Treatment he or she may have previously issued. If the Principal does have such a document in place, he or she should initial the line supplied for item D then indicate the paperwork on file by reporting its Title and Execution Date in the area provided

The final topic here is labeled “E. Autopsy And Disposition Of Remains.” If the Health Care Agent should be limited or restricted in any way when making decisions regarding the Principal’s remains, this should be recorded in this item. Such instructions can be supplied in the area provided and the Principal must initial the blank line to the left of this statement.

5 – The Principal Directive Regarding Organ Donation Should Be Addressed

The next article, “6. Organ Donation,” shall define the Principal’s wishes regarding Organ Donation and Anatomical Gifts unless a separate and unrevoked document is currently in Effect. If the Principal will allow the Health Care Agent to donate “Any Needed Organs Or Parts” then he or she should initial the first statement. However, if the Principal will only allow certain donations, then he or she should initial the second statement and record the Principal’s organs and body parts the Health Care Agent may donate. Only one of these statements should be initialed.

If the Principal intends to approve the Health Care Agent’s Principal Power to make a donation of his or her body for Anatomical Study, then he or she should initial the third statement. The Principal may also document any provisions that should be applied to the Health Care Agent’s Principal Powers when making an Anatomical Gift for Anatomical Study by initialing the fourth statement and using the blank lines presented to report the details of his or her directives.

6 – Some Additional Restrictions May Be Applied

There will be some additional provisions which, again, may be removed or crossed out but, only after consulting a qualified professional (i.e. an Attorney). These additional considerations will be found in the list lettered A through E. The subjects covered here will cover the “Revocation Of Prior Powers Of Attorney,” “Jurisdiction, Severability, and Durability,” declare the “Health Care Agent Not Liable” for decisions made within the scope of this document, guarantee “No Civil OR Criminal Liability” provided all good faith decisions have been made according to these directives, and the Health Care Agent’s ability to seize “Reimbursement.”

7 – The Principal, Two Witnesses, And A Notary Public Must Execute This Appointment

The conclusion of this document will be an acknowledgment statement which will set up the Execution Date. Find the words “This The…” then record the Calendar Day (1-31), Month, and Year when this paperwork is officially put into Effect through the Principal Act of Signing.

The Principal must sign the next blank line at the direction of the Notary Public before two Witnesses.

The next paragraph will solidify the Witness Testimony. Record the Principal’s Name on the blank line following the words “I Hereby State That The Principal…”

Each Witness should report the Current Date on the “Date” line then sign his or her Name on the “Witness” line. There will be enough room for two witnesses to supply these items.

The area below the Witness Testimony can only be fulfilled by a Notary Public. Follow this entity’s directions carefully so this signing can be officially notarized.