Medical Power of Attorney Form

A Medical Power of Attorney (MPOA) 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 another form of 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

A Medical POA is just one type of Power of Attorney. For example, a Financial Power of Attorney is used to appoint an agent to make financial decisions for you.

Table of Contents

• Free Medical Power of Attorney by State
• How to Get a Medical Power of Attorney
• Using a Medical POA
• Free Medical Power of Attorney Samples (PDF & Word)

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.

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.

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 it’s signed, but it only takes effect once a physician certifies you’re incapable of making 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 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 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 and is only responsible for making choices about your health. In addition, they cannot make financial arrangements on your behalf unless you’ve also 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 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 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 provides your agent and healthcare professionals easy access to all of your 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 there are significant differences.

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:

• 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.

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 document is powerless if you become temporarily incapacitated but are expected to recover. Only a Medical Power of Attorney can guide in these situations.

Distribute copies

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 you are 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 automatically has the authority to make healthcare decisions on your behalf. However, if you’ve used this type of document to appoint someone else as your agent, then 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.

At any time while competent, the principal can change the medical POA, including updating the agent and/or successor agents.

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 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.

Universal Medical Power of Attorney

Although the document above is a good example, you should use a Medical Power of Attorney form specific to your state.