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State of
County of ____________
Date:
IMPORTANT — SCOPE NOTICE:
This is a MEDICAL Power of Attorney for healthcare decisions ONLY. This document does NOT grant authority over financial, legal, or property matters. For financial authority, a separate General or Durable Power of Attorney is required. This document takes effect when your attending physician determines you are unable to make your own healthcare decisions, unless you have selected a different effective date.
This is a MEDICAL Power of Attorney for healthcare decisions ONLY. This document does NOT grant authority over financial, legal, or property matters. For financial authority, a separate General or Durable Power of Attorney is required. This document takes effect when your attending physician determines you are unable to make your own healthcare decisions, unless you have selected a different effective date.
KNOW ALL PERSONS BY THESE PRESENTS:
I, ________________, of ________________, ________________, __ _____, born on ________________, being of sound mind and under no duress, do hereby appoint the following person as my Healthcare Agent (Attorney-in-Fact) with authority to make healthcare decisions on my behalf:
I, ________________, of ________________, ________________, __ _____, born on ________________, being of sound mind and under no duress, do hereby appoint the following person as my Healthcare Agent (Attorney-in-Fact) with authority to make healthcare decisions on my behalf:
APPOINTMENT OF HEALTHCARE AGENT:
I hereby appoint ________________, of ________________, ________________, __ _____ (Relationship: ________________), Phone: ________________, as my Healthcare Agent to make healthcare decisions on my behalf as set forth in this document.
I hereby appoint ________________, of ________________, ________________, __ _____ (Relationship: ________________), Phone: ________________, as my Healthcare Agent to make healthcare decisions on my behalf as set forth in this document.
HEALTHCARE POWERS GRANTED:
I grant my Healthcare Agent the following powers to act on my behalf:
I grant my Healthcare Agent the following powers to act on my behalf:
RESUSCITATION PREFERENCES:
________________
________________
PAIN MANAGEMENT PREFERENCES:
________________
The Principal has a constitutionally and common-law protected right to refuse medical treatment, including life-sustaining treatment, as recognized in Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990). The preferences recorded here are the Principal's express instructions and must be followed by the Healthcare Agent and treating providers to the extent permitted by state law.
________________
The Principal has a constitutionally and common-law protected right to refuse medical treatment, including life-sustaining treatment, as recognized in Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990). The preferences recorded here are the Principal's express instructions and must be followed by the Healthcare Agent and treating providers to the extent permitted by state law.
LIMITATIONS AND CONDITIONS:
Effective Date:
Duration:
Effective Date:
Duration:
REVOCATION:
The Principal may revoke this Medical Power of Attorney at any time by providing written notice or oral notification to the Healthcare Agent and/or attending physician. Oral revocation is effective when communicated and must be documented in the Principal's medical record. Revocation does not require that the Principal retain full decision-making capacity.
The Principal may revoke this Medical Power of Attorney at any time by providing written notice or oral notification to the Healthcare Agent and/or attending physician. Oral revocation is effective when communicated and must be documented in the Principal's medical record. Revocation does not require that the Principal retain full decision-making capacity.
PROVIDER RELIANCE & IMMUNITY:
Healthcare providers who in good faith rely on this Medical Power of Attorney are protected from civil and criminal liability under the advance-directive statutes of the State of and, where applicable, the Uniform Health-Care Decisions Act. A provider presented with this document should treat the Healthcare Agent as the Principal's authorized decision-maker.
Healthcare providers who in good faith rely on this Medical Power of Attorney are protected from civil and criminal liability under the advance-directive statutes of the State of and, where applicable, the Uniform Health-Care Decisions Act. A provider presented with this document should treat the Healthcare Agent as the Principal's authorized decision-maker.
GOVERNING LAW:
This Medical Power of Attorney shall be governed by and construed in accordance with the laws of the State of ________________, including but not limited to:
This Medical Power of Attorney shall be governed by and construed in accordance with the laws of the State of ________________, including but not limited to:
PRINCIPAL SIGNATURE:
________________, Principal
________________, Principal
WITNESSES:
I declare that the person who signed this document, or asked another to sign on their behalf, did so in my presence. I am at least 18 years of age and am not the person appointed as Healthcare Agent by this document.
Witness 1:
________________ Date: ____________
Witness Name (Print): ________________________
Witness Address: _____________________________
I declare that the person who signed this document, or asked another to sign on their behalf, did so in my presence. I am at least 18 years of age and am not the person appointed as Healthcare Agent by this document.
Witness 1:
________________ Date: ____________
Witness Name (Print): ________________________
Witness Address: _____________________________
Frequently Asked Questions
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