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Medical Power of Attorney
This free printable form for a medical power of attorney provides a template you can use to define decision making authority regarding medical decisions. The generic template provides initial sections for you to appoint an agent and alternate agent along with revoking any previous versions. It also provides for witnesses and a notary for verification of the form.

Free Sample Template
Format: Word PDF
# of Pages: 2
Printable: Yes


Medical Power of Attorney TemplateForm 4159
Format: Word PDF
Category: Legal, Power of Attorney
Type: POA Agreement

Medical Power of Attorney

I:

Name: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

City: ____________________________________________ State: __________ Zip Code: _____________________

Do hereby appoint:

Name: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

City: ____________________________________________ State: __________ Zip Code: _____________________

Phone Number: ________________________________________________________________________________

Email Address: _________________________________________________________________________________

As my agent to make any medical care decisions for me, except that is otherwise stated in this document. This Medical Power of Attorney will take effect if I become unable to make my own medical care decisions and my primary physician certifies this fact in a written document. The following are the limitations with regard to the decision making authority for my agent: ____________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

If the above agent is unable to make my medical care decisions for me, I hereby designate the following individuals to serve as my agent to make my medical care decisions for me as are authorized by this Medical Power of Attorney:

Alternate Agent:

Name: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

City: ____________________________________________ State: __________ Zip Code: _____________________

Phone Number: ________________________________________________________________________________

Email Address: _________________________________________________________________________________

I hereby understand that this Medical Power of Attorney exists indefinitely from the date that it is executed unless I establish a shorter time or revoke this Medical Power of Attorney. If I am unable to make my own medical care decisions for myself when this power of attorney expires, the authority I have granted my agent or alternate agent continues to exist until the time I become able to make my own medical care decisions.




I hereby revoke any prior Medical Power of Attorney that I have executed previously.

I sign my name to this Medical Power of Attorney on: ___/___/_____

Location: ______________________________________________________________________________________

Address: ______________________________________________________________________________________

City: ____________________________________________ State: __________ Zip Code: _____________________

Signature: ___________________________________________________________________ Date: ___/___/_____

Witness Signature: ____________________________________________________________ Date: ___/___/_____

Witness Signature: ____________________________________________________________ Date: ___/___/_____

Notary Public Acknowledgement:

SEAL

This affidavit was subscribed, sworn to and acknowledged before me this, the _____________ day of the month of

___________________________________, 2______.

Signature of Notary Public: _______________________________________________________________________

My Commission Expires: ___/___/_____