Free Medical Power of Attorney Form

Medical Power of Attorney (MPOA) Forms – By State

Depending on where you live, your medical power of attorney (MPOA) may need to contain specific information and follow certain guidelines. For example, some states have stricter signing requirements or guidelines for who can be a healthcare agent. Legal Templates offers state-specific medical power of attorney forms so you can create one that will be enforceable in your jurisdiction.

What Is a Medical Power of Attorney (MPOA)?

A medical power of attorney (MPOA) or durable power of attorney for healthcare is a legal document that lets you choose a trusted agent to make medical decisions for you. You name your agent (or “attorney-in-fact“) and specify what powers you want them to have. When the MPOA form meets the signing requirements in your state, it becomes legally binding and enforceable.

This document only goes into effect when a doctor determines that you cannot decide your healthcare for yourself. This way, you keep control over your medical decisions while competent.

Legal Templates offers an MPOA form so you can dictate who will be in charge of your treatment. Our template makes it clear that your agent only assumes authority when you’re incapacitated.

When Is an MPOA Needed?

Regardless of their current health, any adult can benefit from having a medical power of attorney. An MPOA ensures you have someone to make decisions to aid your recovery or assist with end-of-life decisions if you become incapacitated. It’s useful when you want to:

• Address health concerns: Appoint someone to manage your care following a serious diagnosis.
• Plan for procedures: Make sure someone can act if unexpected issues arise during medical treatment.
• Reduce family stress: Give loved ones clarity on who you want to handle your healthcare decisions.

Who Makes Medical Decisions Without a Power of Attorney?

If an individual becomes incapacitated and lacks an MPOA, state law dictates who becomes responsible for their medical decisions. In many states, spouses or domestic partners have the first right to this authority.

If they’re unavailable or unwilling, the responsibility typically goes to adult children, parents, or siblings. If no family members are available, the court can appoint a guardian to fulfill the role.

Medical POA vs. Living Will vs. Advance Directive

A medical power of attorney lets you appoint a healthcare agent to make decisions for you when you’re incapacitated, while a living will lets you specify your wishes for end-of-life medical care, including life support, CPR, dialysis, surgical procedures, and palliative care.

Often, individuals write a living will and a medical power of attorney to cover all their bases for healthcare. These two end-of-life documents are examples of advance directives.

With both documents in place, a living will will take priority, as it dictates an individual’s specific healthcare wishes. However, a medical power of attorney can be a good supplementary document if a patient needs care decisions made that they didn’t specify in their living will or situations that the living will does not specify on.

How to Get a Medical Power of Attorney

Writing a medical power of attorney form lets you clearly state who has authority over your health-related matters if you become incapacitated. Plus, it lets you limit the scope of authority to what you’re comfortable granting. Follow these steps to write a legally sound MPOA.

Step 1 – Add Principal’s Information

Name yourself as the principal, who is the person who will benefit from the decisions made via the medical power of attorney. List your name, address, contact information, and date of birth. When you use our template, you can enter all your information in one place, and we’ll fill it in to complete the document.

Step 2 – Name Your Agent

Specify who your agent will be and provide their address and contact information, including their phone number and email address. Ensure you talk to them to confirm their willingness to act as your agent. If they’re not comfortable, choose someone else. Your agent should be able to:

• Follow your preferences when possible
• Adhere to state laws
• Avoid conflicts of interest
• Observe ethical standards

You can also name alternate agents in case your primary one becomes unwilling or unable to act on your behalf. Use our template to designate up to two alternate agents after your primary one.

Step 3 – List Your Agent’s Powers

While agents can have broad authority under an MPOA, their powers are not without limits. Your agent’s authority lies in your hands, so you can decide what they can and cannot do. Depending on your preferences, you can allow your medical POA agent to:

• Approve or decline medical care, treatments, and medications
• Access your medical records
• Approve admission to or discharge from health care facilities
• Authorize participation in medical research
• Arrange or contract health care services or facilities
• Manage or dismiss care personnel involved in your treatment
• Make decisions about organ or tissue donation

Use our template to customize your attorney-in-fact’s powers, ensuring they match your health care preferences. You can also write out special instructions to be more specific about your agent’s authority and limitations.

Step 4 – Write the Effective Date

A medical power of attorney typically takes effect when you become incapacitated. In some cases, incapacitated means when your agent and physician determine that you can’t make decisions for yourself. However, some states have different definitions of incapacity.

Does a Durable Power of Attorney Cover Medical Decisions?

A durable power of attorney for healthcare covers medical decisions. It remains effective through incapacity, allowing your agent to decide on treatments and care plans.

Some durable powers of attorney don’t cover medical decisions. Instead, they grant legal and financial decision-making rights when the principal is unable to act for themselves.

Step 5 – Sign & Seek Notary Acknowledgment

Sign your name to confirm your selections and preferences. A medical power of attorney may need to be notarized, depending on where you live. Even if a notary public doesn’t need to witness your signature, you may need one or more witnesses to observe it. Follow your state’s requirements to ensure compliance. Otherwise, your document won’t be enforceable.

Step 6 – Revise as Needed

If your health condition, personal circumstances, or relationship with your agent changes, you may need to update your MPOA. The easiest way to change it is to revoke the existing form and write a new one. You can revoke an existing medical power of attorney with Legal Templates’s revocation of power of attorney form. Follow your state’s requirements for witnesses or notarization to validate the revocation.

Provide copies of the revocation form to your former agent, health care providers, and anyone else with the original power of attorney for medical decisions. Then, you can appoint a new agent or update your preferences with a new medical power of attorney form.

Sample Medical Power of Attorney

Below, you can view an example of a medical power of attorney form to understand its structure better. When you’re ready, you can fill out your own via our medical power of attorney template. Download it in PDF or Word format.

State of _____________

POWER OF ATTORNEY FOR MY HEALTH CARE

A Simple Health Care Advance Directive

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 Email Address

WARNING: This is a universal medical power of attorney template built to meet the requirements

of most but not all states. We strongly recommend using a state-specific form.

Get My State Form

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 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 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: (Check all that apply)

☐ 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)

☐ 2. 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.

☐ 3. 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.

☐ 4. 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.

☐ 5. To hire and fire medical, social service, and other support personnel who are responsible for my

care.

☐ 6. To authorize my participation in medical research related to my medical condition.

☐ 7. 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.

☐ 8. To decide about organ and tissue donations, autopsy, and the disposition of my remains as the law

permits.

☐ 9. 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.

2. I cancel any previous power of attorney for health care that I may have signed.

3. I intend this power of attorney to be universal; it is valid in any jurisdiction in which it is presented.

4. I intend that copies of this document are as effective as the original.

5. 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

Principal's Name

Date

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 Name

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, ________________________, 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 _________________ )

) (Seal)

County of _________________ )

The foregoing instrument was acknowledged before me this _____ day of _______________, 20_____,

by the undersigned witnesses, ________________________________________________, and

_______________, 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: ________________