When any individual wishes to appoint an attorney or agent of trust & confidence to give them the authority to take decisions on behalf of them in matters related to health care, can fill this form and submit it to the relevant department.
The main form is divided into seven parts beginning with guidelines on how to fill the form and who to choose as the attorney. Initially you need to fill in your full and legal name followed by the present date, state where you are filling the form in and your date of birth. Then fill in the details of the agent you wish to choose including their full and legal name (first, middle, last), complete address with the city state & zip code, daytime phone number, other phone number & email address. If you choose to keep a back-up or a successor agent as well fill in the same details as you did for the primary agent.
Here, the generalized powers that the agent shall hold are stated such as; they shall have the right to agree, refuse or withdraw medical treatment, surgical procedures, tests or medications; shall have access to all medical records; shall authorize the admission or discharge from any facility; hire or fire anyone responsible for your healthcare; to decide about the donation of organs, tissues, etc. If there are any special instructions or limitations for the agent, they can be mentioned in the field below the same. All these powers become effective when the attending physician or the agent-in-fact feels that you are unable to communicate your wise health care decision.
Other provisions for the agent are also stated in the sixth section followed by your signature full name and the date confirming the grant of powers to the agent. There is a statement for the witnesses as well followed by their full name, signatures, date and address. If you are a resident of Missouri, North Carolina, South Carolina or West Virginia then you need to get this form notarized by the Notary Public otherwise it’s optional.
Health Care Power of Attorney Form