Medical Power of Attorney (Healthcare Proxy) Form

This free legal form is provided for general informational purposes. Before you utilize any legal form you find on the Internet, you should have it reviewed by a lawyer in your jurisdiction to be certain that it meets your legal needs, and will be held valid by a court in the jurisdiction where you reside. It is often possible to obtain a free medical power of attorney form, reviewed for legality in your state, from a local hospital.

A medical power of attorney form is usually executed at the same time as a durable power of attorney, a document that authorizes another person to manage your personal and financial affairs in the event that you become incapacitated.

Medical Power of Attorney
Effective Upon Execution

I, Name, a married / unmarried man / woman who resides at address, city, county, state, designate Name of Advocate as my agent (hereinafter my "patient advocate") to act for me, if I should become disabled or legally incapacitated. This document shall become effective upon the date of my disability or legal incapacity and shall not otherwise be affected by my disability or legal incapacity.

Patient Advocate's Name
Patient Advocate's Full Address
Patient Advocate's Phone Number

1. Authority to Act. This power of attorney is effective upon my being unable to make or communicate decisions regarding my medical treatment. This designation is suspended during any period in which I regain the ability to participate in my own medical treatment decisions.

My attending physician and another physician or licensed psychologist shall determine, after examining me, when I am unable to participate in making my own medical decisions.

If applicable, substitute the following language:

My religious beliefs prohibit a medical examination to determine whether I am unable to participate in decisions regarding my medical treatment, and therefore I want this determination to be made by Name.

2. Powers of Patient Advocate. I grant my patient advocate authority to make all healthcare determinations for me. In making decisions on my behalf, my patient advocate shall follow my expressed wishes, written and oral, including those outlined within this power of attorney and within my Living Will. If my patient advocate is unable to determine my wishes based upon my written and oral statements, my patient advocate shall make healthcare determinations for me based upon what he/she believes to be my best interest.

Except as provided in Section 3 below, my patient advocate is authorized as follows:

(Strike any provisions that do not apply and omit the stricken passages from your final power of attorney document. As necessary, renumber the paragraphs for your final document.)
  1. Access to Medical Records. To access my medical records, and to receive from healthcare professionals, healthcare providers, and care facilities information relating to my physical and mental condition, including protected healthcare information, and to disclose the contents of my medical records to others. My patient advocate may sign authorizations for the release of protected healthcare information, and I consent to the release of all such information. I intend that my patient advocate be considered a “personal representative” for all purposes under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and related privacy rules and regulations (including 45 CFR 164.502(g)), and for my patient advocate to be entitled to all information in the same manner as if I personally were making the request.

  2. Choice of Medical Care Providers. To hire and fire medical and other support personnel responsible for my care;

  3. Consent to Medical Treatment. To consent to, refuse, or withdraw consent from all types of medical care, treatment, and procedures; provided that, if I have elected to make a gift of my organs and/or body parts, any withdrawal of medical care, treatment, and procedures shall be performed in a such a manner that my organs and/or body parts are kept vital until they are removed;

  4. Admission and Discharge. To authorize my admission to or discharge from (even against medical advice) any hospital, nursing home, care facility, or hospice care.

  5. Contracts for Care. To contract on my behalf for any healthcare–related service or facility, without my patient advocate incurring personal financial liability for such contracts;

  6. Release. On behalf of me and my estate, to release from liability all persons and entities who act in good-faith reliance on instructions given by my patient advocate and to execute any documents, such as a refusal of treatment form or a do-not-resuscitate order, that a physician or a facility may require to carry out my wishes regarding medical treatment;

  7. Other: Describe

3. Restrictions on Patient Advocate’s Powers. Regardless of the above statements, my patient advocate shall follow the instructions set forth in my Living Will and as described below. In the event that I am determined to be terminally ill or injured, or permanently unconscious:

(Choose the provision that you wish to have applied, strike the others, and omit the stricken passages from your final power of attorney document.)
  • I Want / Do Not Want to have life sustaining treatment if I am terminally ill or injured.
  • I Want / Do Not Want to have life sustaining treatment if I am permanently unconscious.
  • I Want / Do Not Want to receive artificially provided food and hydration in the event that I am terminally ill or injured.
  • I Want / Do Not Want to receive artificially provided food and hydration in the event that I am permanently unconscious.
  • I Want / Do Not Want to receive artificially provided food and hydration on limited a trial basis to see whether I can improve;
  • I Want / Do Not Want to receive artificially provided food and hydration indefinitely, unless it clearly increases my suffering;
  • I Want / Do Not Want to receive artificially provided food and hydration indefinitely.

4. Differences Of Opinion Between Healthcare Providers. Regardless of the above statements, my patient advocate:

(Choose the provision that you wish to have applied, strike the other, and omit the stricken passage from your final healthcare proxy document.)

(Choice 1) If there is a difference of opinion among my treating physicians with regard to my medical treatment, I grant broad discretion to my patient advocate. My patient advocate shall consider the opinions of all of my treating physicians and then choose the medical treatment to be administered to me.

(Choice 2) If there is a difference of opinion among my treating physicians with regard to my medical treatment, I grant no discretion to my patient advocate. My patient advocate shall choose the medical treatment that the majority of my treating physicians recommend.

5. Differences of Opinion Between Family Members.

(Choose the provision that you wish to have applied, strike the other, and omit the stricken passages from your final healthcare proxy document.)

(Choice 1) If there is a difference of opinion among my family members with regard to my medical treatment, I grant broad discretion to my patient advocate. My patient advocate shall consider the opinion of each family member and then choose the medical treatment to be administered to me.

(Choice 2) If there is a difference of opinion among my family members with regard to my medical treatment, I grant no discretion to my patient advocate. My patient advocate shall choose the medical treatment that the majority of my family members prefers.

6. Reliance by Third Parties. Third parties may rely upon the representations of my patient advocate as to all matters regarding powers granted to the patient advocate. No person who relies in good faith on the representations of my patient advocate or the authority granted under this Power of Attorney shall incur any liability to me or to my estate for permitting the patient advocate to exercise any power prior to actual knowledge that the Power of Attorney has been amended, revoked, or terminated by operation of law or otherwise.

If I am unable to participate in making decisions for my care and there is no patient advocate or successor patient advocate to act for me, I request that healthcare providers treat the instructions I have given in this Power of Attorney as conclusive evidence of my wishes and that they be followed.

7. Substitute Patient Advocate. If Name of Advocate is, at any time, unable or unwilling to act, I then appoint Name of First Alternate Advocate, presently residing at Full Address as my patient advocate to serve with the same powers.

If Name of Advocate and Name of First Alternate Advocate are, at any time, both unable or unwilling to act, I then appoint Name of Second Alternate Advocate, presently residing at Full Address as my patient advocate to serve with the same powers.

8. Choice of Law. All questions concerning the validity and construction of this Power of Attorney shall be determined under the laws of State Name

Dated: Date

Signature
Typed Name

Witnesses

I Witness 1, and I, Witness 2 swear under penalty of perjury that the principal of this Living Will is personally known to me, that the principal signed or acknowledged this Living Will in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, and that I am not:

  1. A healthcare provider employed at the healthcare institution or healthcare facility where the principal is receiving healthcare.
  2. An employee of the healthcare provider providing healthcare to the principal;
  3. An employee of the healthcare institution or healthcare facility where the principal is receiving healthcare.
  4. The person appointed as the principal’s agent for healthcare.
  5. Related to the principal by blood, marriage, or adoption.
  6. Entitled to a portion of the principal's estate upon the principal's death under a will or codicil.

Dated: Date

Signature
Witness 1's Typed Name
Witness 1's Address

Signature
Witness 2's Typed Name
Witness 2's Address

Notarization

State of State
County of County

On Date, Name appeared before me and proved to my satisfaction that he/she is the person whose name is subscribed to this Living Will, and acknowledged the due execution of the foregoing instrument.

Signature
Notary Public's Typed Name
Notary public, State of State, County of County.
My commission expires Date.

Acceptance of Designation as Patient Advocate
  • This designation shall not become effective unless the patient is unable to participate in medical treatment decisions.

  • As patient advocate, I shall not exercise powers concerning the patient's care, custody and medical treatment that the patient, if the patient were able to participate in the decision, could not have exercised on his or her own behalf.

  • This designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a patient who is pregnant that would result in the pregnant patient's death.

  • As patient advocate, I may make a decision to withhold or withdraw treatment which would allow the patient to die only if the patient has expressed in a clear and convincing manner that I, as patient advocate, am authorized to make such a decision, and that the patient acknowledges that such a decision could or would allow the patient's death.

  • As patient advocate, I shall not receive compensation for the performance of my authority, rights, and responsibilities, but a patient advocate may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights and responsibilities.

  • As patient advocate, I shall act in accordance with the standards of care applicable to fiduciaries when acting for the patient and shall act consistent with the patient's best interests. The known desires of the patient expressed or evidenced while the patient is able to participate in medical treatment decisions are presumed to be in the patient's best interests.

  • A patient may revoke his or her designation at any time and in any manner sufficient to communicate an intent to revoke.

  • I, as patient advocate may revoke my acceptance to the designation at any time and in any manner sufficient to communicate an intent to revoke.

  • A patient admitted to a health facility or agency has legal rights enumerated under the laws of the State of State.

  • If I am unavailable to act after reasonable effort to contact me, I delegate my authority to the persons the patient has designated as [his/her] successor patient advocate in the order designated below. The successor patient advocate is authorized to act until I become available.

    Dated: Date

    Signature
    Patient Advocate's Typed Name
    Full Address, Phone Number

    Signature
    1st Alternative Patient Advocate's Typed Name
    Full Address, Phone Number

    Signature
    2nd Alternative Patient Advocate's Typed Name
    Full Address, Phone Number

    Copyright © 2003 Aaron Larson, All rights reserved. No portion of this article may be reproduced without the express written permission of the copyright holder. If you use a quotation, excerpt or paraphrase of this article, except as otherwise authorized in writing by the author of the article you must cite this article as a source for your work and include a link back to the original article from any online materials that incorporate or are derived from the content of this article.

    This article was first published on , and was last reviewed or amended on Aug 18, 2016.