MEDICAL POWER OF ATTORNEY

This standardized Medical Power of Attorney form allows you to appoint a trusted person to make health care decisions on your behalf if you are unable to do so.

It includes:

• Appointment of a primary health care agent and alternates
• Authority to make treatment, end-of-life, and facility decisions
• HIPAA authorization for access to medical records
• Optional mental health and organ donation directives
• Space for signatures, witnesses, and notary acknowledgment

Format: Fillable PDF (print or complete digitally)

Use Cases: Hospital admissions, end-of-life planning, HIPAA authorization, medical decision-making

Notarization: Includes a notary section if your state requires it

⚠️ Disclaimer:

This is a general template and may not meet all requirements in every jurisdiction. Laws vary by state regarding witnesses, notarization, and enforceability of medical directives. This document is not a physician’s medical order (such as POLST/MOLST) and does not replace legal or medical advice. Please consult an attorney or qualified health care provider for guidance on your specific situation.

Instructions:

Download instantly after purchase, complete the form, and have it notarized by Utsey Notary Services or any licensed notary of your choice before submitting it to your insurance company.