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MEDICAL POWER OF ATTORNEY FORM
I. NOTICE - This legal document grants you (Hereinafter referred to as the
“Principal”) the right to appoint someone else (Hereinafter referred to as the
“Medical Attorney-in-Fact”) to act on the Principal’s behalf ONLY in the event
that the Principal becomes incapacitated which is described as; A medical
physician stating verbally or in writing that the Principal can no longer make
medical care decisions for them self. The Principal has every right to all their
medical decision making power up to that point in time. The Principal may
include restrictions or requests pertaining to the medical decision making
power of the Medical Attorney-in-Fact. It is the intent of the Medical Attorney-
in-Fact to act in the Principal’s wishes put forth, or, to make medical decisions
that fit the Principal’s best interest. Except for the Principal, all parties
authorizing this agreement must be at least 18 years of age and acting in under
no false pressures or outside influences. Upon authorization of this Medical
Power of Attorney Form it will revoke any previously valid Medical Power of
II. MEDICAL INFORMATION - Upon the Principal’s incapacitation, the Medical
Attorney in Fact has every right to: Receive information about proposed
medical care for the Principal, review any and all of the Principal’s medical
records, and to the disclosure of all the Principal’s medical records.
III. REVOCATION - The Principal has the right to revoke this Medical Power of
Attorney Form at anytime. Any revocation will be effective if the Principal
A.Informs their attending physician either directly or indirectly.
B.Authorizes a new Medical Power of Attorney Form.
C.Authorize a Power of Attorney Revocation Form.
IV. WITNESS & NOTARY - This document is not valid as a Medical Power of
Attorney unless it is acknowledged before a notary public or is signed by at
least two adult witnesses who are present when the Principal signs or
acknowledges the Principal’s signature. No person who is related to the
Principal by blood, marriage, or adoption may be a witness. The Medical
Attorney-in-Fact, Principal’s attending physician, and the administrator of any
nursing home in which you are receiving care also are ineligible to be
witnesses. If there is anything in this document that you do not understand,
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