Medical Power Of Attorney printable pdf download

Medical Power Of Attorney

MEDICAL POWER OF ATTORNEY

DESIGNATION OF HEALTH CARE AGENT.

I, ______________________________ (insert your name) appoint:

Name:

_____________________________________________________

Address:

_____________________________________________________

Phone:

_____________________________________________________

as my agent 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 this fact is certified in writing by my physician.

LIMITATIONS ON THE DECISION-MAKING AUTHORITY OF MY AGENT ARE AS

FOLLOWS:

_______________________________________________________________

DESIGNATION OF ALTERNATE AGENT.

(You are not required to designate an alternate agent but you may do so. An alternate

agent may make the same health care decisions as the designated agent if the designated agent is

unable or unwilling to act as your agent. If the agent designated is your spouse, the designation

is automatically revoked by law if your marriage is dissolved, annulled, or declared void unless

this document provides otherwise.)

If the person designated as my agent is unable or unwilling to make health care decisions

for me, I designate the following persons to serve as my agent to make health care decisions for

me as authorized by this document, who serve in the following order:

First Alternate Agent

Name:

____________________________________________

Address:

____________________________________________

Phone:

____________________________________________

Medical Power of Attorney

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Medical Power Of Attorney