Last revised: 10-02-2023
States have different laws regarding the use of a medical Durable power of Attorney. please, consult an attorney in your State.
Using this Form
Please note that the requirements for a Medical Durable Power of Attorney and the need for witnesses may vary by state. It’s crucial to consult with legal counsel or a healthcare professional in your area to ensure that your DPOA is compliant with your state’s laws and regulations. Additionally, it’s advisable to discuss your preferences with your agent, healthcare provider, and family members to ensure they are aware of your wishes.
Principal Information:
- Full Name: ________________________________
- Date of Birth: ________________________________
- Address: ________________________________
- City: ________________________________
- State: ________________________________
- Zip Code: ________________________________
- Phone Number: ________________________________
Agent Information:
- Name of Agent: ________________________________
- Relationship to Principal: ________________________________
- Address of Agent (if applicable): ________________________________
- City: ________________________________
- State: ________________________________
- Zip Code: ________________________________
- Phone Number: ________________________________
Authorization of Agent: I, [Principal’s Full Name], hereby appoint [Agent’s Full Name] as my agent to make medical decisions on my behalf in the event that I become unable to make or communicate my own healthcare decisions. This authority includes the ability to access and disclose my medical information, including protected health information (PHI) as defined by HIPAA.
Scope of Authority: My agent’s authority shall include, but not be limited to, the following:
- To make decisions regarding medical treatments, procedures, and interventions.
- To access, receive, and disclose my medical information, including medical records and PHI, as necessary to make informed healthcare decisions.
- To consent to or refuse medical treatments, surgery, or other medical procedures on my behalf.
- To consult with healthcare providers and make decisions consistent with my values, wishes, and best interests.
HIPAA Authorization: I authorize my healthcare providers, insurance companies, and other relevant entities to disclose my medical information, including the contents of this DPOA, to my agent for the purpose of making healthcare decisions on my behalf. This authorization complies with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
Duration and Revocation: This DPOA shall remain in effect until I revoke it in writing or until my death. I understand that I have the right to revoke or change this DPOA at any time.
Signature: I have signed this Medical Durable Power of Attorney willingly and in full understanding of its implications on this [Date].
Principal’s Signature: ________________________________
Witnesses (if required by state law):
- Name: ________________________________ Signature: ________________________________ Date: ________________________________
- Name: ________________________________ Signature: ________________________________ Date: ________________________________