POWER OF ATTORNEY FOR HEALTHCARE
THIS POWER OF ATTORNEY is made on [Date],
BETWEEN:
Principal: [Full Name of Principal], residing at [Principal Address] (“Principal”)
AND
Agent: [Full Name of Agent], residing at [Agent Address] (“Agent” or “Attorney-in-Fact”)
WHEREAS
- The Principal desires to appoint the Agent to make healthcare decisions on their behalf in the event that the Principal is unable to make such decisions;
- The Agent is willing to accept this appointment and act in the best interests of the Principal.
NOW, THEREFORE, the parties agree as follows:
1. APPOINTMENT OF AGENT
1.1 The Principal hereby appoints [Agent Full Name] as their true and lawful Agent (also known as Attorney-in-Fact) to make healthcare decisions on the Principal’s behalf.
1.2 If [Agent Full Name] is unable or unwilling to serve, the Principal appoints [Alternate Agent Name], residing at [Alternate Agent Address], as alternate Agent.
2. EFFECTIVE DATE
2.1 This Power of Attorney for Healthcare becomes effective when the Principal’s attending physician determines in writing that the Principal lacks the capacity to make or communicate healthcare decisions.
3. POWERS GRANTED
3.1 The Agent is authorized to make all healthcare decisions for the Principal, including but not limited to:
- Consent to, refuse, or withdraw any type of medical care, treatment, or procedure;
- Admit or discharge the Principal from any hospital, nursing home, or other medical facility;
- Access and disclose the Principal’s medical records as needed;
- Make decisions regarding organ donation, autopsy, and disposition of remains, subject to any written instructions by the Principal;
- Employ or discharge healthcare providers.
3.2 The Agent must act in accordance with the Principal’s wishes as expressed in this document or otherwise known to the Agent. If the Principal’s wishes are not known, the Agent must act in the Principal’s best interests.
4. LIMITATIONS
4.1 [Insert any specific limitations, restrictions, or instructions here, e.g., “The Agent shall not authorize withdrawal of artificial nutrition and hydration unless specifically directed by the Principal.” If none, write “None.”]
5. DURATION AND REVOCATION
5.1 This Power of Attorney for Healthcare shall remain in effect until revoked by the Principal in writing or upon the Principal’s death.
5.2 The Principal may revoke this Power of Attorney for Healthcare at any time by providing written notice to the Agent and any healthcare provider involved in the Principal’s care.
6. RELIANCE BY THIRD PARTIES
6.1 Any third party, including healthcare providers, may rely upon the representations of the Agent as to all matters relating to any power granted to the Agent.
7. GOVERNING LAW
7.1 This Power of Attorney for Healthcare shall be governed by and construed in accordance with the laws of [Governing Law State/Country].
8. MISCELLANEOUS
8.1 Photocopies or electronic copies of this document shall have the same effect as the original.
8.2 The Agent is entitled to reimbursement for reasonable expenses incurred while acting under this Power of Attorney, but is not entitled to compensation unless otherwise specified: [Insert “None” or specify terms].
9. DISCLAIMER
This document is a template and may not be suitable for all situations. The parties should consult with legal counsel before signing this agreement.
SIGNATURES
Principal:
Signature: ___________________________
Printed Name: [Principal Name]
Date: [Date]
Agent:
Signature: ___________________________
Printed Name: [Agent Name]
Date: [Date]
Alternate Agent (if any):
Signature: ___________________________
Printed Name: [Alternate Agent Name]
Date: [Date]
WITNESS ATTESTATION
We, the undersigned witnesses, declare that the Principal is personally known to us, appears to be of sound mind, and signed or acknowledged this Power of Attorney for Healthcare in our presence.
Witness 1:
Signature: ___________________________
Printed Name: [Witness 1 Name]
Address: [Witness 1 Address]
Date: [Date]
Witness 2:
Signature: ___________________________
Printed Name: [Witness 2 Name]
Address: [Witness 2 Address]
Date: [Date]
NOTARY ACKNOWLEDGMENT (if required)
State of [State], County of [County]
On this [Date], before me, [Notary Name], a Notary Public in and for said State, personally appeared [Principal Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Signature of Notary: ___________________________
Printed Name: [Notary Name]
My Commission Expires: [Expiration Date]
Seal: [Notary Seal]
