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Ohio Medical Power of Attorney Form

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Ohio Medical Power of Attorney Form

Updated August 09, 2023

An Ohio medical power of attorney allows a principal to choose someone else (“agent” or “attorney-in-fact”) to make health care decisions on their behalf. The power granted in this document only becomes available when the principal can no longer think for themselves. The principal can also choose to select additional agents in case the primary agent is not able to serve.


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1 – The Form To Appoint Health Care Power Is Obtainable On This Page

Use one of the buttons beneath the image to gain access and download this document. You may choose any of the formats provided. The Principal should read it through especially the first part which contains some important definitions to consider. When it is time to fill it out, begin by filling out the Principal’s Full Name on the first blank line after the title and his or her Birth Date on the second blank line after the Title.

2 – Identify All The Health Care Agents Who Can Wield Principal Power

Two types of Health Care Agents can be named here as having the Principal Authority to make medical decisions on behalf of the Principal if he or she is rendered incapable of doing so. The Health Care Agent will gain access to these Powers automatically as a result of this paperwork’s execution while the First and Second Alternate Agents will only assume Principal Power if the Health Care Agent cannot or does not. These back-up Agents will be eligible to use Principal Power in the order listed. Thus, the Second Alternate Agent will only assume Authority if both the Health Care Agent and the First Alternate Agent do not.

First, locate the statement labeled “Naming Of My Agent.” Notice the three blank lines provided here: “Agent’s Name,” “Agent’s Current Address,” and “Agent’s Current Telephone Number.” Satisfy the blank lines associated with these labels with the information they call for by printing out the Health Care Agent’s Full Name, Residential Address, and Telephone Number. Next, find the paragraph labeled “Naming Of Alternate Agents.” There will be two columns provided here: “First Alternate Agent” and “Second Alternate Agent.” Use the “First Alternate Agent” column to document the Name, Address, and Phone Number of the individual who will assume Principal Authority when the Health Care Agent Cannot. Then, use the “Second Alternate Agent” column to report the Full Name, Address, and Telephone Number of the individual assuming the Principal Power to make Health Care Decisions should the Health Care Agent and Primary Agent be unable or unwilling to.

3 – The Principal Must Review The List Of Health Care Powers

Now that we have declared the Health Care Agent(s), it will be time for the Principal to review the numbered list provided under the paragraph labeled “Authority Of Agent.” Each statement that should not be included may be deleted or crossed out if the Principal has decided it should not be a decision or action the Health Care Agent should have the Power to engage in.

Item 1 will allow the Health Care Agent to make decisions regarding Pain Relieving Drugs/Treatments/Procedures. The Principal may cross this out if the Health Care Agent should not be able to provide Principal Consent to such care.The second item will deal with the scenario of the Principal in a Terminal Condition. This statement will grant the Health Care Agent with the ability to give or not give Principal Consent for life-sustaining/prolonging treatment and artificial nutrition/hydration. If the Principal wishes to restrict the Health Care Agent from such Power, this statement should be removed or crossed out.Item 3 will have the wording to allow the Health Care Agent to give Principal Consent or Refusal to medical procedures on behalf of the Principal. Remove this statement if it should not apply to the Health Care Agent’s ability to represent the Principal’s interests.The fourth statement has been provided if the Health Care Agent should have access and the right to review any and all of the Principal’s Medical Information. It may be removed if such Powers should be withheld from the Health Care Agent.The Health Care Agent can give consent to or disclose the Principal’s Medical Information to third parties by virtue of the fifth statement. This statement may be crossed out or altogether removed if the Health Care Agent should not have such Principal Powers.The Principal will automatically give the Health Care Agent the right to execute other Principal documents if such actions are required to obtain medical information. This Authority may be restricted from Health Care Agent access if this statement is deleted or struck through with a horizontal line.The seventh statement will provide the Health Care Agent with the Principal Authority to execute waivers or consents on behalf of the Principal if it is left alone. Such Power may be withheld if this statement is crossed out or deleted.The Health Care Agent will have the Principal Authority to decide who the Health Care Personnel responsible for the Principal’s well-being can or cannot be through the language in statement 8. Cross out or delete this item if the Principal does not wish the Health Care Agent to have Principal Authority in this matter.In statement 9, the Health Care Agent will be granted Principal Power to decide where and when the Principal is admitted to a medical facility for treatment. It may be crossed out or deleted if the Principal wishes to restrict the Health Care Agent’s Power from this type of Principal Power.In the event the Principal is rendered incapacitated where this document is not effective, statement 10 will appoint the Health Care Agent the Principal Authority to transport the Principal to a Health Care Facility that will honor the Principal Preferences of this document (including the Health Care Agent Appointment). Delete or strike through this statement to exclude it from the Health Care Agent’s Principal Powers.Statement 11 will specifically give the Health Care Agent the ability to sign documents on behalf of the Principal. These can be consents for Health Care Treatment, Do Not Resuscitate Orders, requests for transfers or discharge (even against medical advice), and any other document not described. Any part of or this entire statement may be excluded from the assigned Principal Powers by crossing it out or deleting it.

4 – Additional Instructions May Be Applied By The Principal

The next section the Principal should review is headed by a paragraph labeled with the words “Special Instructions.” This area will deal with the Health Care Agent’s preferences regarding artificial Nutrition/Hydration. Statement 1 allows the Health Care Agent to determine if artificial nutrients and liquids should be withdrawn or denied the Principal when he or she is in a permanently unconscious state while Statement 2 will require at least two Physicians to verify that artificial Nutrition/Hydration will provide comfort to the Principal. Statement 3 will provide a blank line the Principal should initial if he or she wants to apply these statements to this document’s effect. The Principal may withhold the Power to make this type of decision in these circumstances if he or she does not initial this blank line.If the Principal has any additional instructions or wishes to place any limitations or restrictions on the Health Care Agent’s ability to wield Principal Authority, they should be supplied to the blank lines under the paragraph labeled “Additional Instructions Or Limitations.”

5 – The Principal Must Address Some Related Directives

Find the term “Living Will” in bold lettering after the “Additional Instructions Or Limitations” section. If the Principal has completed a Living Will, then place a check mark on the line labeled “Yes” here. If not, then place a check mark on the blank line labeled “No.”If the Principal has documented his or her wishes regarding Organ Donation in his or her Living Will, then place a check mark on the line labeled “Yes” in the “Anatomical Gift(s)” paragraph. If not, or if the Principal has not developed a Living Will, then check mark the blank line labeled “No.”If the Principal has completed a “Donor Registry Enrollment Form,” check mark the “Yes” line in the “Donor Registry Enrollment Form” statement. If not, then check mark the “No” line.

6 – The Witnessed Or Notarized Signature Of The Principal Must Be Furnished

In order for the directives in this paperwork to be respected by any Health Care Provider, Physician, Facility, etc., it must be signed by the Principal. He or she should provide the Signature Date using the first two blank lines in the “Signature” section and the City where he or she signed this document on the third blank line.

The Principal must sign the “Principal” line on the Date reported above in the city reported above. This document may be substantiated through a witnessing of the Principal Signing or through its notarization. If the Principal Signing will be validated by two Witnesses, then each one must provide his or her Signature, Printed Name, Address, and Signature Date on the blank line labeled “Signature,” “Print Name,” “Residing At,” and “Dated” just below the “Witnesses” paragraph in the “Witnesses Or Notary Acknowledgment” section. If this signing will be Notarized, the Notary Public may utilize the area labeled “Notary Acknowledgment” for this process.