Medical Power of Attorney (MPOA) Form

A Medical Power of Attorney form lets you choose an agent to make healthcare decisions for you ( the principal ) if you become incapacitated and unable to communicate your wishes.

The Medical POA goes into full effect only after a licensed physician deems the principal incapacitated and unable to make decisions.

Your agent can only act on your behalf regarding treatment, medication, or surgery options if your doctor determines you can’t make decisions for yourself due to dementia, coma, or other incapacity.

Medical Power of Attorney – by State

Since each state has unique legislation regarding this legal document, you must use the correct legal form.

Table of Contents

• Medical Power of Attorney - by State
• Statutory Forms - by State
• Signing Requirements
• How to Get a Medical Power of Attorney
• Medical Power of Attorney Sample
• Frequently Asked Questions

Statutory Forms – by State

You can find the official name below, as the name of the form differs by state.

Signing Requirements

States have different requirements for MPOA forms to be witnessed, but they need to be authorized in the presence of witnesses, a notary public, or both. This is the requirement that your signature be witnessed.

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.

Step 1 – 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.

Step 2 – 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 the following:

• Life support, tube feeding, CPR
• Admittance or discharge from healthcare facilities
• Medical research
• Palliative care
• Organ or tissue donation
• Disease treatment

Step 3 – Include Living Will or DNR.

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.

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 a Medical POA, a living will doesn’t appoint an agent to make healthcare decisions for you. A living will is 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)
• dialysis
• 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.

Step 4 – Sign the form and distribute copies.

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.

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.

Medical Power of Attorney Sample

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.

Frequently Asked Questions