Simple Medical Power of Attorney
A simple medical power of attorney form is used to authorize an agent to make health care decisions on behalf of the grantor. It also includes limitations relating to life support, and life prolonging treatment services. It is effective upon execution.
Sample Simple Medical Power of Attorney
I,…………. [Name], a resident of ………… [Address. County, State]; Social
Security Number ……………… [Number] designate ……………………. [Name],
presently residing at ……………. [Address], telephone number
……………… [Phone number] as my agent to make any and all health care
decisions for me, except to the extent I state otherwise in this document. For the purposes
of this document, “health care decision” means consent, refusal of consent, or withdrawal
of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an
individual’s physical or mental condition. This medical power of attorney form takes
effect if I become unable to make my own health care decisions and this fact is certified
in writing by my physician.
Statement of witnesses
I hereby declare under penalty of perjury that the person who signed this document is personally known to me to be the principal. That the principal signed this simple medical power of attorney form in my presence. That the principal appears to be of sound mind and under no duress, fraud or undue influence. I am not the agent, nor related to the principal by blood, marriage or adoption. I have no claim against any portion of the principal’s estate on the principal’s death.
Witness
Witness
Subscribed and sworn to before me on (DATE)………….
Notary Public (county, state)
My commission expires…………………
Category: Power of Attorney forms
