Free Medical Power of Attorney Form

Table of Contents

• What is a medical power of attorney (MPOA)?
• How to fill out a medical power of attorney form
• Using a medical POA

1. What is a medical power of attorney (MPOA)?

A Medical Power of Attorney (also known as an advance directive or health care proxy) is a legal document used to appoint someone (referred to as an agent) to make medical decisions on your behalf. Your agent’s authority only begins after you’ve been declared incompetent and unable to communicate your wishes by your doctor — for example, if you fall into a coma.

The state you live in may refer to a medical power of attorney by a different name, such as:

• Health care power of attorney (healthcare POA)
• Durable power of attorney for health care
• Advance directive
• Medical POA

Medical POA vs living will

Unlike an MPOA, a living will doesn’t appoint an agent to make healthcare decisions for you. A living will by definition is a legal document that describes your life-sustaining and end-of-life medical treatment preferences in specific scenarios. For example, a living will may detail your instructions regarding:

• organ or tissue donation
• life support
• cardiopulmonary resuscitation (CPR)
• dialysis
• surgical procedures
• palliative care
• other medical treatments

Any instructions included in your living will must be followed by your health care providers, and can’t be influenced by your family or friends. But what if you find yourself in a medical situation that your living will doesn’t cover?

In such an event, you’ll need a medical power of attorney. Without one, your healthcare decisions and preferences might be appointed to someone you don’t know or trust.

Finally, a living will is only effective once you’re diagnosed as terminally ill, permanently unconscious, or declared to be in a similar end-stage condition. This means your living will is powerless if you become temporarily incapacitated but are expected to recover. Only a medical power of attorney can provide guidance in these situations.

3. How to fill out a medical power of attorney form

To get a legal medical power of attorney, you need to choose your agent, determine your agent’s authority, sign the form according to your state’s requirements, including other advance directives, distribute copies.

Your medical power of attorney form becomes effective immediately once it’s signed, but your agent can only make medical treatment decisions after you’ve been declared incompetent.

Choose your agent

Most states legally require your agent to be 18+ years of age, mentally competent, and not an owner, operator, administrator, or employee of a healthcare facility where you’re a patient.

Your agent will advocate for your well-being and medical preferences while you’re incapacitated. You should select a friend, family member, spouse, or professional who is:

• Someone you trust to follow your wishes and act in your best interests
• Knowledgeable of your desired treatments as well as religious and moral beliefs
• Emotionally capable of making difficult choices on your behalf
• Willing to accept the responsibility of the role
• Available to consult with your physician(s) to make decisions

A health care agent can also be referred to as a health care proxy, patient advocate, or surrogate decision-maker.

Can you have more than one MPOA agent?

In addition to your primary agent, you’re able to designate one or more alternate agents, also known as successor agents. Your alternate agent will assume responsibility in the event that your first choice is unwilling, unable, or unavailable.

Is your medical power of attorney agent responsible for medical bills?

No, your agent is not responsible for your medical bills and is only responsible for making choices about your health. In addition, they cannot make financial arrangements on your behalf unless you’ve also given them durable powers of attorney over your financial matters.

Define your agent’s authority

It’s up to you to define the scope of your agent’s authority. Unless you include limitations in your MPOA form, they will have the authority to make choices for you relating to your medical care, medications, treatments, surgeries, physicians, medications, and more.

To ensure your wishes are followed, consider specifying whether your patient advocate is able to make decisions regarding:

• Life support, tube feeding, CPR
• Admittance or discharge from healthcare facilities
• Medical research
• Palliative care
• Organ or tissue donation
• Disease treatment

Can your agent access your medical records?

Yes, your patient advocate has the authority to access your medical records as outlined in the HIPAA Privacy Rule 45 CFR 164.524.

Sign the form following your state’s requirements

For your medical POA to be legally-binding, it must comply with your state’s signing requirements. If you don’t follow those requirements, your signature may not be recognized and your form might be deemed invalid.

Does a medical power of attorney have to be notarized?

Most states require you to sign the document in the presence of either two witnesses or notary public, and some states require both.

For example, Florida and Texas require two witnesses’ signatures. In California, you can choose between a notary public or two witnesses. Meanwhile, in Colorado there are no requirements, but a notary public is recommended.

Your state may also impose restrictions on who can act as your witness. For instance, someone related to you by blood or marriage and/or your healthcare providers may be barred from signing as a witness.

Include other advance directive orders (optional)

If you’ve completed other advance directive orders such as a Living Will or Do-Not-Resuscitate, you can attach them to your medical power of attorney form. This provides your agent and healthcare professionals easy access to all of your detailed healthcare wishes.

Distribute copies

Once you’ve certified your document with witness or notary public signatures, file the original in your personal records and distribute copies to your:

• Primary agent
• Alternate agent
• Primary physician
• Loved ones
• Witnesses
• Healthcare institutions where you receive care
• Residential / palliative care facilities you live in

Always bring a copy of your medical power of attorney if you are admitted to the hospital, even for an outpatient procedure.

Distributing copies of your MPOA is critical. Your advance directives will only be followed if your healthcare providers can access them in your time of need.

4. Using a medical POA

All US citizens 18+ years of age will benefit from using a medical power of attorney form. You may be motivated to create one if you are:

• Military personnel deployed overseas
• Traveling abroad for an extended period
• Diagnosed with a chronic condition or life-threatening disease
• Participating in extreme sports or activities
• Engaged in a high-risk profession
• Celebrating a milestone birthday

What happens if you have no power of medical attorney?

If you become incapacitated and don’t have an MPOA, a legal guardian (often a family member) will be appointed to manage your medical affairs. Unfortunately, the person selected as your guardian might not be someone you trust to make decisions for you.

Does your spouse automatically have medical power of attorney?

Yes. In most states, if you’re legally married and have never signed an MPOA, your spouse automatically has the authority to make healthcare decisions on your behalf. However, if you’ve used a medical POA form to appoint someone else as your agent, then they have the authority to make your healthcare decisions over your spouse.

How long does medical power of attorney last?

An MPOA is effective unless it’s revoked, includes an expiration date, the principal becomes competent, or the principal dies.