A Medical Power of Attorney form lets you choose an agent to make healthcare decisions for you if you become incapacitated and unable to communicate your wishes. Your agent can only act on your behalf if your doctor determines you can’t make decisions for yourself due to dementia, coma, or other incapacity.
The state you live in may refer to this form by a different name, such as:
- Healthcare Power of Attorney (Healthcare POA)
- Durable Power of Attorney for Health Care
- Healthcare Proxy
Free Medical Power of Attorney Samples (PDF & Word)
Below is a free blank template you can download in PDF or Word format, print out, and fill out independently. Click on the download button at the bottom of the form, or view a filled-out PDF to see what the final draft should look like.
Although the document above is a good example, you should use a Medical Power of Attorney form specific to your state.
Free Medical Power of Attorney by State
Since each state has unique legislation regarding this legal document, you must use the correct legal form. Look for your state in the list below and download your state-specific template.
- District of Columbia
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Rhode Island
- South Carolina
- South Dakota
- West Virginia
You can also get your state’s MPOA form at a local hospital, doctor, or healthcare provider. Alternatively, you can download a completed form using our step-by-step document builder.
A Medical POA is just one type of Power of Attorney. For example, a Financial Power of Attorney appoints an agent to make financial decisions for you.
How to Get a Medical Power of Attorney
To create a legal Medical Power of Attorney, you must choose your agent, determine your agent’s authority, and sign the form according to your state’s requirements. If you wish, you may also include other advance directives (such as a living will).
Your form is legally binding once signed but only takes effect once a physician certifies you cannot make health care decisions.
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 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 healthcare agent can also be referred to as a healthcare proxy, patient advocate, or surrogate decision-maker.
Can you have more than one MPOA agent?
In addition to your primary agent, you can designate one or more alternate agents, also known as successor agents. Your alternate agent will assume responsibility if your first choice is unwilling, unable, or unavailable.
Is your Medical POA agent responsible for medical bills?
No, your agent is not responsible for your medical bills but only for making choices about your health. In addition, they cannot make financial arrangements unless you’ve designated them as your Power of Attorney over 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 power to make choices for you relating to your medical care, medications, treatments, surgeries, physicians, and more.
To ensure your wishes are followed, consider specifying whether your patient advocate can 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 can 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 a notary public, and some states require both.
You can choose between a notary public or two witnesses in California and Texas. For example, Florida requires two witnesses’ signatures. Meanwhile, there are no requirements in Colorado. Nonetheless, we still recommend a notary public.
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.
Consider including other Advance Directives
If you’ve completed other Advance Directives, such as a Living Will or a Do-Not-Resuscitate form, you can attach them to your Medical Power of Attorney form. This gives your agent and healthcare professionals easy access to detailed healthcare wishes.
MPOA vs. Living Will
Medical powers of attorney and living wills are considered advance directives for health care. The two documents can often work together as part of a complete estate plan, but significant differences exist.
Unlike an MPOA, a living will doesn’t appoint an agent to make healthcare decisions for you. A living will is defined as a legal document stating your preferences regarding specific life-sustaining and end-of-life medical treatments. For example, a Living Will may detail your instructions regarding the following:
- organ or tissue donation
- life support
- cardiopulmonary resuscitation (CPR)
- surgical procedures
- palliative care
- other medical treatments
Your healthcare providers must follow any instructions in your living will and can’t be influenced by your family or friends.
Finally, a Living Will is only practical once you’re diagnosed as terminally ill, permanently unconscious, or declared to be in a similar end-stage condition. This means your document is powerless if you are temporarily incapacitated but are expected to recover. Only a Medical Power of Attorney can guide in these situations.
Once you’ve certified your document with witness or notary public signatures, you should file the original in your records and distribute copies to your:
- Primary agent
- Alternate agent
- Primary physician
- Loved ones
- Healthcare institutions where you receive care
- Residential/palliative care facilities you live in
Always bring a copy of your MPOA if admitted to the hospital, even for an outpatient procedure.
Using a Medical POA
All Americans 18+ years of age will benefit from using this 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 Medical Power of 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 can make healthcare decisions on your behalf. However, if you’ve used this type of document to appoint someone else as your agent, they have the authority to make your healthcare decisions over your spouse.
How long does a Medical Power of Attorney last?
A Medical Power of Attorney lasts until:
- the principal (if competent) revokes it
- the principal dies
- the form includes a termination clause or expiration date
- the agent and any successor agents die, become incapacitated, or resign.
While competent, the principal can change the medical POA, including updating the agent and/or successor agents.