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The North Carolina health care power of attorney is a legal document used by the grantor to authorize the attorney-in-fact to make decisions about his/her health care matters.
STATE OF NORTH CAROLINA
HEALTH CARE POWER OF
COUNTY OF __________________
NOTE: YOU SHOULD USE THIS DOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE
AGENT IF YOU ARE COMFORTABLE GIVING THAT PERSON BROAD AND SWEEPING POWERS
TO MAKE HEALTH CARE DECISIONS FOR YOU. THERE IS NO LEGAL REQUIREMENT THAT
ANYONE EXECUTE A HEALTH CARE POWER OF ATTORNEY.
1. Designation of Health Care Agent.
I, _______________________________, being of sound mind, hereby appoint the following person(s) to serve as
my health care agent(s) to act for me and in my name (in any way I could act in person) to make health care
decisions for me as authorized in this document. My designated health care agent(s) shall serve alone, in the order
A. Name: _____________________________ Home Telephone: _________________________
Home Address: _____________________________ Work Telephone: _________________________
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