A Durable Power of Attorney for Health Care form gives your chosen Agent the authority to make all medical decisions on your behalf in the event that you cannot make decisions on your own. Fill out a free Durable Power of Attorney for Health Care form in just minutes online.
Durable Power of Attorney for Health Care is a legal device used for estate planning purposes giving your trusted Agent the authority to act on your medical affairs when you are not able to due to incompetency or incapacity. With Durable Power of Attorney for Health Care, the Principal appoints the Agent of his or her own choosing instead of a judge deciding on a court-appointed conservator to make medical decisions for you.
Free Durable Power of Attorney for Health Care Form
Durable Power of Attorney for Health Care gives your Agent the authority to make all medical decisions on your behalf in the event you become incapacitated. It is imperative to take your time, outlining all medical decisions the Agent should make and instructions for the kind of health care treatment you want.
Select your State and POA form below then click Create Document to start your free Durable Power of Attorney for Health Care form:
Sample Free Durable Power of Attorney for Health Care Form
This sample free Durable Power of Attorney for Health Care form is an example of the information needed to fill out a typical Durable Power of Attorney for Health Care form. This is a cut and paste free Durable Power of Attorney for Health Care form. Feel free to tailor the information to the form as needed to fit your needs. We strongly suggest that if you have any questions about filling out a Durable Power of Attorney for Health Care form, you should consult a lawyer.
Durable Power of Attorney for Health Care
________________________________________________________
Principal
1.Agent. I choose ______________________________as my Agent with full authority
to manage my health care.
2.Alternate. If ______________________________is unable or unwilling to act, I choose
___________________________as my Agent with full authority to manage my health
care.
3. My Rights. I keep the right to make health care decisions for myself as long as I am
capable.
4. Durable. My Agent can still use this power of attorney document to manage my affairs
even if I become sick or injured and cannot make decisions for myself. This power of
attorney shall not be affected by my disability.
5. Start Date. This power of attorney document is effective on the day I sign it in front
of a notary public.
6. End Date. This power of attorney document will end if I revoke it or when I die.
If my spouse or domestic partner is my Agent, this power of attorney document will
end if either of us files for divorce in court.
7. Revocation. I revoke any other power of attorney for health care documents I have
signed in the past. I understand that I may revoke this power of attorney document
at any time by giving written notice of revocation to my Agent.
8. Powers. My Agent shall have full power and authority to do anything as fully and
effectively as I could do myself, including the power to make health care decisions and
give informed consent to my health care, refuse and withdraw consent to my health
care, employ and discharge my health care providers, apply for and consent to my
admission to a medical, nursing, residential or other similar facility that is not a mental
health treatment facility, serve as my personal representative for all purposes under
the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended,
and to visit me at any hospital or other medical facility where I reside or receive
treatment.
9. Mental Health Treatment. My Agent is not authorized to arrange for my
commitment to or placement in a mental health treatment facility. My Agent is not
authorized to consent to electrotherapy, psychosurgery, or other psychiatric or
mental health procedures that restrict physical freedom of movement.
10. No Power to Agree to Binding Pre-Dispute Arbitration. I recognize that
some long-term care providers will ask me or my Agent to sign a binding pre-dispute arbitration
agreement. These agreements limit my right to sue the provider before any injury or
dispute occurs. I think these agreements are unfair and unacceptable. Therefore, my agent
does not have the power to agree to pre-dispute binding arbitration or any other process
involving my person or property that limits my right to a jury, to sue for money, or to join
a class action.
10. Accounting. My Agent shall keep accurate records of my finances and show these
records to me at my request.
11. Nomination of Guardian. I nominate my Agent as the guardian of my estate for
consideration by the court if guardianship proceedings become necessary.
12. HIPAA Release. I authorize my healthcare providers to release all information governed
by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to my Agent.
_________________________________________
Principal Signature
_____________________
Date
Notarization
State of ________________________
County of _______________________
I certify that I know or have satisfactory evidence that__________________________,
is the person who appeared before me, signed above, and acknowledged that the signing
was done freely and voluntarily for the purposes mentioned in this instrument.
Subscribed and Sworn to before me on _____________________.
________________________
Notary
Notary Public for the State of __________________.
My commission expires _________________.