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Medical Power of Attorney Form









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Medical Power of Attorney

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Medical Power of Attorney


Effective Date ____/____/______

I, do hereby [Legal Name]
A resident of [City][State]
Located at [Address]
[City], [State] [Zip Code]

Do Hereby Appoint [Legal Name]
A resident of [City][State]
Located at [Address]
[City], [State] [Zip Code]

As my attorney-in-fact to make any and all health care decisions for me, except to the extent I state otherwise in this document. This Medical Power of Attorney takes effect if I become unable to make my own health care decisions and my physician certifies this fact in writing. The following are limitations on the decision making authority of my agent:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

If the above designated person as my agent is unable or unwilling to make healthcare decisions for me, I hereby designate the following persons to serve as my agent to make health care decisions for me as is authorized by this document, who may serve in the following order:

First Alternate:

Do Hereby Appoint [Legal Name]

A resident of [City][State]

Located at [Address]

[City], [State] [Zip Code]

Second Alternate:

Do Hereby Appoint [Legal Name]

A resident of [City][State]

Located at [Address]

[City], [State] [Zip Code]

This power of attorney is to start to be effective on ____/____/______, and shall remain effective until ____/____/______. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent continues to exist until the time I become able to make health care decisions for myself. I hereby revoke any prior Medical Power of Attorney that I have made in the past. I do hereby grant my attorney-in-fact complete and full authority to act in any reasonable and necessary manner for the purpose of exercising the above mentioned powers. I also, ratify all the lawfully performed acts by my attorney-in-fact in exercising those powers. I fully understand and agree that any third party who is given a copy of this Power of Attorney may act relying on it. I also, agree that revocation of this Power of Attorney is effective as to a third party only when they receive receipt of an actual notice by the third party. If due to reliance on the Power of Attorney, a third party suffers any loss, I agree to pay for any third party loss.

I sign my name to this Medical Power of Attorney on:

____________ Day of ____________ Month ____________ Year



__________________________________________________________
Signature


By accepting this appointment and acting under it, I the attorney-in-fact (“Agent”) do hereby assume the legal responsibilities of an agent.


_____________________________________________________________________Date____________
Signature of Attorney-in-Fact


WITNESS #1) _________________________________


WITNESS #2) _________________________________









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