Medical power of attorney form: free to fill in and download in Word

What the template includes

• Health care agent and an alternate
• Starts only when you cannot decide
• Authority over treatment, doctors, facilities and records
• Your wishes on life-sustaining treatment and pain relief
• Other personal and religious wishes
• Limits on the agent
• HIPAA access for the agent
• Two witness statements and a notary page

What you fill in

How it gets signed

1. 1Download the medical power of attorney in Word and fill in the fields.
2. 2Print it and read every power once more before you sign.
3. 3Sign it on paper, before a notary or witnesses when your state asks for them.
4. 4Give the original to your agent and keep a copy with your records.

Most states ask for two adult witnesses, a notary or both for a medical power of attorney, and limit who can be a witness, such as the agent or your health care provider. Your state’s form lists its rules. Sign here, then complete the witness or notary step your state requires.

What the law says

Each state has its own health care power of attorney or advance directive law. Many states publish a statutory form. A form from another state is often honored, but your own state’s form avoids questions.

The HIPAA Privacy Rule treats a health care agent acting under a valid power as the patient’s personal representative. Clause 6 makes that access explicit.

Medical power of attorney or living will

A medical power of attorney names a person. A living will states your wishes in writing. This form does both in one document. Many states also combine them under the name advance directive.

Choosing a health care agent

• Someone who will follow your wishes even if they disagree.
• Someone who can stay calm and talk with doctors.
• Someone who lives close enough to be at the hospital.
• Not your doctor or a staff member of your care facility.

Talk about your wishes

The form helps, but conversations matter more. Tell your agent what you value. Being at home, avoiding pain or trying every treatment are all valid choices.

Give copies to your agent, your doctor and the hospital where you are usually treated. Keep one where your family can find it.

A worked example

Linda names her daughter Sofia as agent and her son as alternate. She writes that she does not want life support if permanently unconscious and prefers care at home.

Two neighbors watch her sign and sign as witnesses. Linda gives a copy to her doctor, who adds it to her chart.

Sample wishes people write

• “I want all treatment that may help me recover, even if the chance is small.”
• “If I am permanently unconscious, I do not want a feeding tube.”
• “I want to die at home if possible, with hospice care.”
• “I want a chaplain of my faith called if I am seriously ill.”
• “I wish to donate any organs that may help others.”

Write in your own words. Short, clear statements help your agent and your doctors.

Where to keep copies

• With your agent and your alternate.
• In your medical record, through your doctor.
• At home, in a place your family knows.
• A photo or scan on your phone that you can show at the hospital.

Review it every few years

Look at it again after a new diagnosis, a divorce or a move to another state. A new signed form replaces the old one under clause 8.

Checklist before you sign

1. 1Agent and alternate agreed to act.
2. 2Wishes written in your own words.
3. 3Witnesses meet your state’s rules.
4. 4Notary booked if your state asks for one.
5. 5Copies ready for your agent and your doctor.

Then sign, have the witnesses sign and hand out the copies the same week.

Bring a copy to every hospital admission. Staff add it to your chart and know whom to call.

Ask staff to confirm your agent’s phone number at each visit.

Update it there if you change agents.

Before you sign

• Power of attorney for medical decisions
• What a health care proxy is

Other templates

• Durable power of attorney
• HIPAA authorization
• Power of attorney
• Enduring power of attorney worksheet
• Consent form