Free Medical Power of Attorney Form

Table of Contents

1. 1. Download a Free Blank Medical Power of Attorney Form
   2. What is a Medical Power of Attorney (MPOA)?
   3. Who Should Have a Durable Health Care Power of Attorney?
   4. How to Select Your Agent(s)
   5. Your Agent’s Authority
   6. How to Complete Your Medical Power of Attorney Form
   7. Health Care Power of Attorney (Healthcare POA) State Laws

1. Download a Free Blank Medical Power of Attorney Form

Free Blank Printable Medical Power of Attorney Form Download

2. What is a Medical Power of Attorney (MPOA)?

A Medical Power of Attorney (MPOA) is a legal document that allows you to name a healthcare agent — someone who will make medical decisions in the event you become incapacitated and unable to communicate your wishes. Your agent will advocate for your care and ensure your medical wishes are followed.

By definition, a simple Medical Power of Attorney form will include the following key terms:

• Healthcare Agent: someone who is at least 18 years old that you trust and deem mentally competent enough to make healthcare decisions for you.

• Alternate Agent: someone who is authorized to make medical decisions on your behalf in the event your healthcare agent is unavailable or unable to make those decisions.

• Agent Authority: authority granted to a healthcare agent to make decisions in accordance with your personal values or that are in your best interest.

• Effective Authority: authority that can only be wielded after a doctor declares your inability to make your own healthcare decisions.

• Guardian: someone you nominate to be your legal guardian if required by court.

Also note that your state may refer to a Medical Power of Attorney form by a different name, such as:

• Health Care Proxy
• Health Care Power of Attorney (Healthcare POA)
• Durable Health Care Power of Attorney
• Medical Durable Power of Attorney
• Advance Directive

Difference Between a Medical Power of Attorney and a Living Will

While a simple Medical Power of Attorney allows you to designate an agent to make medical and end-of-life decisions on your behalf, a Living Will is a legal document that allows you to describe your medical care and end-of-life preferences in specific scenarios. For example, a Living Will may detail your instructions regarding:

• organ or tissue donation
• extended artificial life support
• resuscitation
• dialysis
• other medical treatments

Any instructions included in your Living Will must be followed by your healthcare providers, and can’t be influenced by your family or friends.

Unlike an MPoA, a Living Will does not appoint an agent to make decisions for you. Consequently, your loved ones and health care providers may be uncertain how to handle a scenario outside its established parameters.

Furthermore, a Living Will is only effective once you’ve been diagnosed as terminally ill, in a permanent state of unconsciousness, or a similar end-stage condition. This means your document is of no use if you become temporarily incapacitated due to an unexpected illness or injury but are expected to recover.

Many states consolidate a Medical Power of Attorney and Living Will into a legal single document referred to as an Advance Directive. This document empowers you to spell out your medical care and end-of-life preferences as well as appoint a healthcare agent to make decisions on your behalf.

3. Who Should Have a Durable Health Care Power of Attorney?

All Americans 18+ years of age will benefit from creating a Durable Health Care Power of Attorney form.

It’s a common misconception that you only need a Medical Power of Attorney if you’re elderly or suffering from a terminal illness.

Unfortunately, life can be unpredictable. We all run the risk of suffering an unexpected illness or injury that could leave us unable to communicate our wishes.

Having a completed Healthcare POA form will ensure you receive the care you desire in such an event, and that someone you trust is advocating for your care.

You may be motivated to create a Medical Durable Power of Attorney if you are:

• Military personnel being deployed overseas
• Traveling abroad for an extended period of time
• Diagnosed with a chronic condition or life-threatening illness
• Getting married and want your spouse to have legal authority over your care
• Participating in extreme sports or activities that put your health at risk
• Engaged in a high-risk profession (i.e. emergency firefighter or police officer)
• Celebrating a milestone birthday

The Consequences of Not Having a Medical Power of Attorney

If you become incapacitated and don’t have a valid Medical Durable Power of Attorney, your loved ones will need to legally appoint a guardian to manage your medical decisions.

Unfortunately, this process wastes valuable time, and quickly racks up expensive legal fees. Furthermore, it can lead to conflict over who should be your guardian, as well as debate over what type of medical and end-of-life treatment you would have wanted.

Use our free Medical Power of attorney form to save your loved ones from uncertainty, legal hassle, and potential conflict.

4. How to Select Your Healthcare Agent(s)

Selecting a healthcare agent for your Durable Medical Power of Attorney is a difficult decision that shouldn’t be taken lightly.

The majority of states require your agent to be 18+ years of age and mentally capable. Additionally, your agent should be a friend, family member, or professional who is:

• Knowledgeable of your religious and moral beliefs
• Emotionally capable of making difficult decisions on your behalf
• Willing to accept the responsibility of acting as your agent
• Available to consult with your physician(s) and make treatment decisions

Many states don’t allow an operator, administrator, or employee of a healthcare facility at which you’re a patient to act as your agent. Exceptions can be made if you’re related to the individual by blood or marriage.

Can You Have More Than One Agent?

Most states allow you to select one or more alternate agents, also known as successor agents, in addition to your primary agent. Your alternate agent will assume decision making responsibility in the event your first choice is unwilling, unable, or unavailable to act as your agent.

5. Your Healthcare Agent’s Authority

Unless you include limitations in your Medical Power of Attorney form, your agent is able to make any and all healthcare decisions on your behalf.

In order to ensure your wishes are followed, consider specifying whether your agent is able to make the following decisions for you regarding:

• Mental Health Treatment
• Nursing Homes
• Artificial Nutrition and Hydration
• Release of Medical Records
• Medical Treatment
• Organ Donation

6. How to Complete Your Medical Power of Attorney Form

In order for your Medical Power of Attorney form to be legally-binding, it must comply with the signing requirements set forth by your state.

Most states require you to sign your Health Care Power of Attorney in the presence of either two witnesses or a notary public – and some states require both.

In addition, your state may impose restrictions on who can act as your witness. For example, individuals related to you by blood or marriage may be barred from signing your document as a witness.

Alternatively, select states have special witness requirements that you must follow if the circumstances apply to you. For example, if you’re a patient at a skilled nursing facility, you may be required to have a patient advocate or ombudsman serve as a special witness as you sign your Durable Health Care Power of Attorney.

To avoid creating an invalid Medical Power of Attorney, it’s crucial that you review the signing and witness requirements of your state.

What to do With Your Signed Medical Power of Attorney

Once you’ve certified your Medical Power of Attorney with the appropriate signature(s), you should file the original in your personal records and distribute copies of the document to:

• Your primary agent
• Your alternate agent(s)
• Your primary physician
• Residential care facilities you reside in
• Healthcare institutions at which you receive care
• Your loved ones

Additionally, you should consider keeping a copy of your Medical Power of Attorney with you at all times, such as in your purse or wallet, so that it can be easily accessed in an emergency. Always bring a copy of the document with you if you are admitted to the hospital, even for an outpatient procedure.

7. Health Care Power of Attorney
(Healthcare POA) State Laws

It’s important to note that each state has its own unique legislation regarding the creation, revocation, and validity of a Medical Durable Power of Attorney. You should review the legislation of the state in which you plan to execute your document and/or consult an attorney before drafting your form.