Medical Power of Attorney Form

Our free Medical Power of Attorney form can be used as sample document to assist you in compiling your personalized form.

It is important to refer to our guidelines to know:

  • Who may NOT be appointed as your Attorney for health care matters
  • Who may NOT sign as witnesses
  • Whether to appoint more than one Agent, whether you want decisions to be made jointly/severally and the implications thereof
  • The template 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.

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Answers to the above can be found here and for an overview and links to related health care forms, please visit our Power of Attorney Main Page

Important Note for our visitors from England and Wales: The information on our page for a Lasting POA for Health and Welfare is specifically compiled for you.

The heading on the form below 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 also contact a hospital in your jurisdiction to review any free legal forms that they may have available to the public.









Copyright Notice



Power of Attorney for Health Care

I, the undersigned

(Full legal name)


(Identity/Social Security number)



residing at

(Address)




revoke any and all previous Power of Attorney for Health Care made by me and appoint

(Full legal name)


(Identity/Social Security number)



residing at

(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)



residing at

(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.



* * *

You can add as many detailed instructions to your Agent as you wish on your medical power of attorney form.





You are here:

» » Medical POA Template





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