Medical Power of Attorney Template

MEDICAL POWER OF ATTORNEY / HEALTHCARE PROXY I. Appointment of Agent

I, [Patient Name], being of sound mind, hereby appoint the following person as my agent to make health care decisions for me if I become unable to make such decisions for myself.

Agent Name: [Name] Address: [Address] Phone: [Phone] II. Alternate Agent

If the person named above is unable or unwilling to act as my agent, I appoint the following alternate agent:

Alternate Name: [Name] Address: [Address] Phone: [Phone] III. Powers of Agent

My agent has full power and authority to make health care decisions for me, including:
1. Consenting to, refusing, or withdrawing medical treatment.
2. Accessing my medical records to make informed decisions.
3. Choosing providers and facilities.
4. Making decisions about life-sustaining treatment (consistent with my Living Will, if any).

IV. Limitations

My agent may not make decisions about:
[ ] None (Agent has full authority)
[ ] Specific limitations: [Describe]

V. Effectiveness

This Medical Power of Attorney becomes effective only when my attending physician certifies in writing that I lack the capacity to make my own health care decisions.

VI. Signature

Signed this [Day] day of [Month], [Year].

Signature: __________________________

[Patient Name]

VII. Witnesses

We declare that the person signing this document appeared to be of sound mind and acting voluntarily.

Witness 1: __________________________ Date: _____________ Witness 2: __________________________ Date: _____________