Medical Power Of Attorney Form (Page 2 of 3) in pdf

Medical Power Of Attorney Form Page 2

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

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Medical Power Of Attorney Form Page 2