Set up a
HE FORM below is provided as an educational example of a limited power of attorney form. In most cases, this form will not be legal in your location. But this will give you an idea of the content of a typical form. The form you use should be obtained locally from appropriate sources.
This form is provided here as an example only and does not constitute legal advice. Consult properly authorized professionals in your community to obtain the correct form for the legal jurisdiction where you live.
Health Care Power of Attorney I, __________________________, as principal, designate _________________ as my agent for all matters relating to my health care, including, without limitation, full power to give or refuse consent to all medical, surgical, hospital and related health care. This power of attorney is effective on my inability to make or communicate health care decisions. All of my agent's actions under this power during any period when I am unable to make or communicate health care decisions or when there is uncertainty whether I am dead or alive have the same effect on my heirs, devisees and personal representatives as if I were alive, competent and acting for myself. If my agent is unwilling or unable to serve or continue to serve, I hereby appoint ____________________ as my agent. I have _____ I have not _____ completed and attached a living will for purposes of providing specific direction to my agent in situations that may occur during any period when I am unable to make or communicate health care decisions or after my death. My agent is directed to implement those choices I have initialed in the living will. I have _____ I have not _____ completed a prehospital medical care directive. This health care directive is made under state law, and continues in effect for all who may rely on it except those to whom I have given notice of its revocation. ___________________________ Signature IN WITNESS WHEREOF, I have hereunto set my hand and seal this _______ day of _______________________, 20____. Signed, sealed and delivered in the presence of: _____________________________ _____________________________ Witness _____________________________ Witness State of _____________ ) ) ss. County of ____________ ) The foregoing instrument was acknowledged by me this ______ day of _____________, 20 ____ by:_______________________________ who is/are personally known by me or who has/have produced:_____ ______________________ as identification and who did not take an oath. ________________________________ (SEAL) Notary Public State of My Commission Expires: