Medical Power of Attorney (POA) Template
KNOW ALL MEN BY THESE PRESENTS, THAT I, [PRINCIPAL NAME] (“the Principal”), holder of [PRINCIPAL ID DOCUMENT] number [PRINCIPAL ID NUMBER] and residing at [PRINCIPAL ADDRESS] do hereby make and appoint as my lawful attorney for me and in my place and in my stead [ATTORNEY NAME] (“the Attorney”), holder of [ATTORNEY ID DOCUMENT] number [ATTORNEY ID NUMBER] and residing at [ATTORNEY ADDRESS] empowering him/her to do all of the following and do hereby ratify and endorse all those things which my true and lawful attorney may do or cause to be done:
The ‘Principal’ means the person giving the medical power of attorney. The ‘Attorney’ means the person who will make the medical decisions (i.e. the recipient of the power). The ‘Attorney’ does not need to be a lawyer, in this context the term simply means someone representing someone else. Typically medical powers of attorney would be used to appoint partners, trusted friends or members of the close family as the Attorney. It is also useful in domestic situations where, for example, one partner has an estranged spouse. A medical power of attorney may be relevant to samesex couples where the law of their country or state does not automatically give medical authority to their partner or spouse in the event of the Principal’s incapacity and to unmarried couples who nevertheless wish to grant medical authority to their partners in the event of their incapacity.
To exercise any and all of the following listed powers in my place and in my stead in the event that I become unable or unfit to make decisions about my own health care and that this fact is certified in writing by a competent practising physician:
By default this template medical power of attorney is written to come into effect only if the patient loses the ability to make their own healthcare decisions. As an alternative you can give the power of attorney without this condition by deleting the above paragraph.
1. Request, receive and review any and all documents relating to my physical and mental health including but not limited to medical information, medical and hospital records, commitment papers, discharge papers, medical notes and test results for whatever reason the Attorney may see fit and to share these documents and their contents with any third party as the Attorney may in their absolute discretion see fit.
2. To discuss freely and fully with any third party including any medical practitioner or representative of any hospital or medical practice the particulars of my medical case.
3. To attend to any formalities whatsoever that the Attorney considers are necessary or conducive to the request of the information listed above including the execution on my behalf of request forms and the application to a competent Court or medical authority in my stead.
4. To request, authorize, instruct and consent to any and all medical treatments including but not limited to invasive and experimental treatments that the Attorney shall in their absolute discretion see fit and without any obligation to give reasons or justification and regardless that the decision may be contrary to medical advice.
5. To instruct a change of physician or physicians, treatment or treatments, hospital or medical practice for whatever reason the Attorney may in their absolute discretion see fit and without any obligation to give reasons or justification and regardless that the decision may be contrary to medical advice.
6. To instruct the transfer of the Principal to another place of treatment or to remove and to discharge the Principal from any place of treatment for whatever reason the Attorney may in their absolute discretion see fit and without any obligation to give reasons or justification and regardless that the decision may be contrary to medical advice.
7. To instruct the withdrawal or cessation of any and all medical treatments for whatever reason the Attorney may in their absolute discretion see fit and without any obligation to give reasons or justification and regardless that the decision may be contrary to medical advice.
This Medical Power of Attorney shall be effective from the date of its execution and shall remain in force indefinitely unless revoked.
Signed this [DAY] of [MONTH], [YEAR] in the presence of two independent witnesses.
This is a medical power of attorney which gives authority to someone else to make decisions about your medical treatment. It gives complete discretion to the the attorney-in-fact (the person receiving the power,) however it can be revoked at any point. Requirements for executing medical powers of attorney vary from state to state to country to country and if you are in doubt about how to execute this document you should consult a lawyer. We have adopted a very cautious approach to execution by stating that this medical power of attorney should be executed in the presence of two independent witnesses. It may be that this level of formality is not required in your state or country, or that some other method is prescribed. If you are unsure of the level of formality required then you should take legal advice before executing this medical power of attorney. It is important to note that in many states and countries there are certain medical treatments which cannot be delegated by power of attorney including, for example, abortion or commitment to a medical institution.
We, the undersigned witnesses, do hereby declare under penalty of perjury that we have witnessed the Principal whose name, identity and handwriting are known to us signing and executing this Medical Power of Attorney in our presence. Further we declare that we are not related to the Principal by blood nor by marriage nor by adoption nor are we involved in providing medical treatment to the Principal nor are we beneficiaries under the Principal’s Last Will and Testament and that the Principal appears, in our best judgement, to be acting in sound mind, voluntarily and free from external influences, stress, duress and undue influence.
[WITNESS 1] [WITNESS 2]
[WITNESS 1 ADDRESS] [WITNESS 2 ADDRESS]
You may also wish to include the ID numbers of the witnesses in case they are later required to verify that they saw the document being signed. As still further proof you might want to have this document signed before a Notary Public. Please see our comments above (1st Panda Tip) regarding the proper execution of medical powers of attorney and if in doubt take legal advice.