Medical Power of Attorney FormThis free Medical Power of Attorney form can be used as sample document to complete your personalized form. 
More power of attorney forms and additional guidelines are available on our Main Page for a Free Power of Attorney Form The heading on this form is Power of Attorney for Health Care. You can also name it: Medical Power of Attorney, or Health Care Proxy Form A quick call to your friendly local attorney can clarify what the form is called in your state or country. You can add as many detailed instructions as you wish to your Agent on the medical power of attorney form. Be sure to comply with the legal requirements for the medical power of attorney form. The format supplied here appoints a health care Agent and then refers to the Living Will (which has detailed instructions) as an attachment. You can combine the two forms into one if you wish.
Power of Attorney for Health CareI, the undersigned (Full legal name) ______________________________ (Identity/Social Security number) ______________________________ (Address) ____________________________________ ____________________________________ revoke any and all previous Power of Attorney for Health Care made by me and appoint (Full legal name) ________________________________ (Identity/Social Security number) ______________________________ (Address) ____________________________________ ____________________________________ to be my Agent for my health and personal care. If my Agent is unable or unwilling to serve, I appoint (Full legal name) ________________________________ (Identity/Social Security number) ______________________________ (Address) ____________________________________ ____________________________________ as substitute agent for my health and personal care. 1. I direct my Agent to make health care decisions according to my wishes as set out in my Health Care Directive (Living Will) attached hereto. 2. I further authorize my Agent to make personal care decisions for me if I am mentally unable to do so. 3. This Power of Attorney for Health Care shall take effect when I become unable to make my own health care decisions and it shall remain in full force and effect until my death unless I revoke it. Executed this ______ day of __________________20 ____ at ______________________________________ Signature: ________________________________ in the presence of the undersigned witnesses: Declaration of Witnesses As witnesses we declare that the above named person is personally known to us, appears to be of sound mind and signed this directive willingly and free of undue influence or duress. We are legal adults and are not related to him / her by blood, marriage or adoption and are not appointed as agents in this directive. To our knowledge we are not beneficiaries of his / her estate and have no claims against his / her estate. We are not directly involved in his / her health care. We declare that he / she signed this will in our presence as we signed as witnesses in the presence of each other, all being present at the same time. Under penalty of perjury we declare these statements to be true and correct on this ___________________ day of ____________________ 20____ at _________________________________. Witness 1. Name: ______________________ Address: _____________________________________________ Signature: ________________________ Witness 2. Name: ______________________ Address: _____________________________________________ Signature: ________________________
Note: If you want to appoint more than one Agent, you must add one of the following statements: I give my Agents the authority to act jointly. OR I give my Agents the authority to act jointly and severally.
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