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Medical Power Of Attorney Form

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-OFFICIAL-

MEDICAL POWER OF ATTORNEY FORM

I. NOTICE - This legal document grants you (Hereinafter referred to as the

“Principal”) the right to appoint someone else (Hereinafter referred to as the

“Medical Attorney-in-Fact”) to act on the Principal’s behalf ONLY in the event

that the Principal becomes incapacitated which is described as; A medical

physician stating verbally or in writing that the Principal can no longer make

medical care decisions for them self. The Principal has every right to all their

medical decision making power up to that point in time. The Principal may

include restrictions or requests pertaining to the medical decision making

power of the Medical Attorney-in-Fact. It is the intent of the Medical Attorney-

in-Fact to act in the Principal’s wishes put forth, or, to make medical decisions

that fit the Principal’s best interest. Except for the Principal, all parties

authorizing this agreement must be at least 18 years of age and acting in under

no false pressures or outside influences. Upon authorization of this Medical

Power of Attorney Form it will revoke any previously valid Medical Power of

Attorney Form.

II. MEDICAL INFORMATION - Upon the Principal’s incapacitation, the Medical

Attorney in Fact has every right to: Receive information about proposed

medical care for the Principal, review any and all of the Principal’s medical

records, and to the disclosure of all the Principal’s medical records.

III. REVOCATION - The Principal has the right to revoke this Medical Power of

Attorney Form at anytime. Any revocation will be effective if the Principal

either:

Informs their attending physician either directly or indirectly.

Authorizes a new Medical Power of Attorney Form.

Authorize a Power of Attorney Revocation Form.

IV. WITNESS & NOTARY - This document is not valid as a Medical Power of

Attorney unless it is acknowledged before a notary public or is signed by at

least two adult witnesses who are present when the Principal signs or

acknowledges the Principal’s signature. No person who is related to the

Principal by blood, marriage, or adoption may be a witness. The Medical

Attorney-in-Fact, Principal’s attending physician, and the administrator of any

nursing home in which you are receiving care also are ineligible to be

witnesses. If there is anything in this document that you do not understand,

you should ask a lawyer to explain it to you.

Medical Power Of Attorney Form

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