Fillable Medical Power Of Attorney Form (Page 4 of 6) in pdf

Medical Power Of Attorney Form Page 4

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medical decisions on my own, I grant my Medical Attorney-in-Fact to decide the

following on my behalf:

1. To give informed consent to any health care procedure;

2. To sign any documents necessary to carry out or withhold any health

care procedures on my behalf; including any waivers or releases of

liabilities required by any health care provider;

3. To give or withhold consent for any health care or treatment;

4. To revoke or change any consent previously given or implied by law for

any health care treatment;

5. To arrange for or authorize my placement or removal from any health

care facility or institution;

6. To require that any procedures be discontinued, including the

withholding of any medical treatment and/or aid, including the

administration of nutrition, hydration, and any other medical procedure

deemed necessary to provide me with comfort, care, or to alleviate

pain, subject to the conditions earlier provided in this document.

7. To authorize the administration of pain-relieving drugs, even if they may

shorten my life.

VIII. ACKNOWLEDGEMENT BY PRINCIPAL - I, the Principal, declare that all

wishes with respect to medical decision making powers be carried out through

the authority that I have herein provided to my Medical Attorney-in-Fact,

despite any contrary wishes, beliefs, or opinions of any members of my family,

relatives, or friends. Also, I have read the document, and understand the full

importance of this appointment, and I am emotionally and mentally competent

to make this appointment of Medical Attorney-in-Fact. I intend for my Medical

Attorney-in-Fact under this Medical Power of Attorney Form to be treated as I

would be with respect to my rights regarding the use and disclosure of my

individually identifiable health information or other medical records. This

release authority applies to any information governed by Health Insurance

Portability and Accountability Act of 1996 (otherwise known as “HIPAA”), 42

USC 1320d and 45 CFR 160-164.

I acknowledge that I have read the document. I understand the full importance

of this appointment. I am over 18 years of age and I am emotionally and

mentally competent to make this appointment of Medical Attorney-in-Fact.

Date__________________

Signature o f P rincipal G ranting M edical P ower o f A ttorney a nd A ppointing M edical

Attorney-‐in-‐Fact ( Signed i n F ront o f N otary P ublic)

Medical Power Of Attorney Form Page 4

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