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Home Legal Documents Power of Attorney Medical

Free Medical Power of Attorney Form

Use our Medical Power of Attorney form to let someone make medical decisions for you if you become unable to do so.

Updated October 27, 2020

A Medical Power of Attorney form, sometimes known as an advance directive or health care proxy, is a document used to give someone the legal authority to make medical decisions for you.

You should use a medical power of attorney form if you’d like to prepare for a future event in which you may be temporarily incapacitated (e.g. under anesthesia), or disabled or incapacitated in a more long-term capacity for other health reasons.

A medical power of attorney form is different from a living will, which is a document that details your wishes regarding the specific types of medical care you do and don’t want to receive. Medical power of attorney, on the other hand, simply allows someone to make those (and other) medical decisions for you.

Table of Contents

  1. What is a medical power of attorney (MPOA)?
  2. Free medical power of attorney forms by state
  3. How to get medical power of attorney
  4. Using a medical POA
  5. Free blank printable medical power of attorney form

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

A medical POA is just one type of power of attorney. For example, a financial power of attorney (also commonly known as a general power of attorney, or simply, power of attorney) is used to elect an agent to make financial decisions for you.

Related Resource: What is a Power of Attorney?

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.

Living wills are often confused with other estate planning documents. Learn the difference between a living will and an advance directive today.

2. Free medical power of attorney by state

Since each state has unique legislation regarding medical power of attorney forms, it’s important that you use the correct form.

To download a free, blank, and printable medical power of attorney form valid in your state, simply click on the state you live in.

Medical Power of Attorney Forms by State

  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming

You can also get your state’s MPOA form at a local hospital, doctor, or healthcare providers. Alternatively, you can download a completed medical power of attorney from our builder for free.

3. How to get medical power of attorney

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, include 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 a 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.

The cost of creating a medical power of attorney is between $0 -$50. You can download a free medical POA form, but you may need to pay for a notary public’s signature.

Include other advance directive orders (optional)

If you’ve completed other advance directive orders 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.

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 Americans 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
  • Travelling 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 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.

5. Free blank printable medical power of attorney form

Below is a simple medical power of attorney template. We have free blank medical power of attorney forms to print. Simply click on the download button at the bottom of the form, or view a filled PDF to see what the final draft should look like.

Universal Medical Power of Attorney

This form combines the many different state legal requirements into a “universal” legal form that is intended to meet the basic requirements in most states. This form has space so you can add any special instructions or limitations you wish to include. But remember, this form is a basic Health Care Power of Attorney. It is not meant for a lengthy statement of your wishes and preferences. Remember, you should discuss your wishes and priorities directly with your agent and with others who are close to you.

INFORMATION ABOUT THE PRINCIPAL

___________________________________________________________________________________

Principal’s Full Name

___________________________________________________________________________________

Principal’s Street Address

___________________________________________________________________________________

City                                                                State                                                         Zip Code

___________________________________________________________________________________

Principal’s Daytime Phone                         Principal’s Other Phone

___________________________________________________________________________________

Principal’s Birthday                                    Principal’s Email Address


WHO WILL BE YOUR HEALTH CARE AGENT?

___________________________________________________________________________________

Agent’s Full Name

___________________________________________________________________________________

Agent’s Street Address

___________________________________________________________________________________

City                                                                State                                                         Zip Code

___________________________________________________________________________________

Agent’s Daytime Phone                             Agent’s Other Phone

___________________________________________________________________________________

Agent’s Birthday                                        Agent’s Email Address

WHO WILL BE YOUR BACK-UP AGENT(S)?

If my first agent is unwilling or unable to act for any reason, then my next choice is:

___________________________________________________________________________________

Back-up Agent’s Full Name

___________________________________________________________________________________

Back-up Agent’s Street Address

___________________________________________________________________________________

City                                                                State                                                         Zip Code

___________________________________________________________________________________

Back-up Agent’s Daytime Phone                                Back-up Agent’s Other Phone

___________________________________________________________________________________

Back-up Agent’s Birthday                                            Back-up Agent’s Email Address

If the first two agents are not willing or able to act for any reason, then my next choice is:

___________________________________________________________________________________

Second Back-up Agent’s Full Name

___________________________________________________________________________________

Second Back-up Agent’s Street Address

___________________________________________________________________________________

City                                                                State                                                         Zip Code

___________________________________________________________________________________

Second Back-up Agent’s Daytime Phone                         Second Back-up Agent’s Other Phone

___________________________________________________________________________________

Second Back-up Agent’s Birthday                                     Second Back-up Agent’s Email Address


WHAT WILL YOUR AGENT’S POWERS BE?

My agent knows my goals and wishes based on our conversations and on any other guidance I may have written. My agent has full authority to make decisions for me about my health care according to my goals and wishes. If the choice I would make is unclear, then my agent will decide based on what he or she believes to be in my best interests. My agent’s authority to interpret my wishes is intended to be as broad as possible, and includes the following authority:

  1. To agree to, refuse, or withdraw consent to any type of medical care, treatment, surgical procedures, tests, or medications. [This includes decisions about using mechanical or other procedures that affect any bodily function, such as artificial respiration, artificially supplied nutrition and hydration (that is, tube feeding), cardiopulmonary resuscitation, or other forms of medical support, even if deciding to stop or withhold treatment could or would result in my death. ______ (Principal’s initials)]
  1. To have access to medical records and information to the same extent that I am entitled to, including the right to disclose health information to others.
  1. To authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care, assisted-living or similar facility or service.
  1. To contract for any health care-related service or facility for me, or apply for public or private health care benefits, with the understanding that my agent is not personally financially responsible for those contracts.
  1. To hire and fire medical, social service, and other support personnel who are responsible for my care.
  1. To authorize my participation in medical research related to my medical condition.
  1. To agree to or refuse using any medication or procedure intended to relieve pain or discomfort, even though that use may lead to physical damage or dependence or hasten (but not intentionally cause) my death.
  1. To decide about organ and tissue donations, autopsy, and the disposition of my remains as the law permits.
  1. To take any other action necessary to do what I authorize here, including signing waivers or other documents, pursuing any dispute resolution process, or taking legal action in my name.

 

DO YOU HAVE SPECIAL INSTRUCTIONS OR LIMITATIONS FOR YOUR AGENT?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

WHEN WILL THIS POWER BE EFFECTIVE?

 

This Power of Attorney for My Health Care will become effective during any time in which, in the opinion of my agent and attending physician, I am unable to make or communicate a choice about a particular health care decision.

 

OTHER PROVISIONS

  1. Health care providers can rely on my agent. No one who relies in good faith on any representations by my agent or back-up agent will be liable to me, my estate, my heirs or assigns, for recognizing the agent’s authority.
  1. I cancel any previous power of attorney for health care that I may have signed.
  1. I intend this power of attorney to be universal; it is valid in any jurisdiction in which it is presented.
  1. I intend that copies of this document are as effective as the original.
  1. My agent will not be entitled to compensation for services performed under this power of attorney, but he or she will be entitled to reimbursement for all reasonable expenses that result from carrying out any provision of this power of attorney.

 

SIGNATURE

I understand the contents of this document and the effect of granting powers to my agent.

_____________________________________ ________________________

Principal’s Signature Date

_____________________________________

Principal’s Name

 

A STATEMENT BY YOUR WITNESSES

I declare that I personally know you ─ the person who signed this document ─ or I have adequate proof of your identity, and that you signed or acknowledged this Power of Attorney for My Health Care in front of me, and that you appear to be of sound mind and under no duress, fraud, or undue influence.

I am an adult and am NOT any of the following:

  1. Appointed as your agent or back-up agent
  2. Related to you by blood, marriage, domestic partnership, or adoption, nor a spouse of any such person.
  3. Your health care provider, including the owner or operator of a health, long-term care, or other residential or community care facility serving you
  4. An employee of your health care provider
  5. Financially responsible for your health care
  6. An employee of your life or health insurance provider
  7. A creditor of yours or entitled to any part of your estate under a will or codicil, trust, insurance policy, or by operation of intestate succession laws.
  8. Entitled to benefit financially in any other way after you die.

 

First Witness

Witness Signature Date
Witness Name
Witness Address
City State Zip Code

Second Witness

Witness Signature Date
Witness 2Name
Witness Address
City State Zip Code

 

NOTARY ACKNOWLEDGEMENT OF PRINCIPAL

State of _______________________ ) (Seal)

County of _____________________ )

The foregoing instrument was acknowledged before me this _______ day of __________________, 20_____, by the undersigned, _______________ [principal’s name], who is personally known to me or satisfactorily proven to me to be the person whose name is subscribed to the within instrument.

_____________________________________

Signature

_____________________________________

Notary Public

My Commission Expires: ________________

 

NOTARY ACKNOWLEDGEMENT OF WITNESSES

State of _______________________

County of ______________________

)

) (Seal)

)

The foregoing instrument was acknowledged before me this _______ day of __________________, 20_____, by the undersigned witnesses, _______________ [witness 1 name], and _______________ [witness 2 name], who are personally known to me or satisfactorily proven to me to be the person whose name is subscribed to the within instrument.

_____________________________________

Signature

_____________________________________

Notary Public

My Commission Expires: ________________

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Although the document above is a good example, you should use a medical power of attorney form specific to your state.

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