Print and Complete a Power of Attorney Form (PDF File)

A Health Care Power of Attorney is a document that allows you to name a person to act on your behalf to make health care decisions for you if you become unable to make them for yourself. This person becomes an attorney-in-fact for you.

• A Health Care Power of Attorney is different from a financial power of attorney that you use to give someone authority over your financial matters.
• The person you appoint as your attorney-in-fact by completing the Health Care Power of Attorney form has the power to authorize and refuse medical treatment for you. This authority is recognized in all medical situations when you are unable to express your own wishes. Unlike a Living Will, it is not limited to situations in which you are terminally ill or permanently unconscious. For example, your physician or the hospital may consult with your attorney-in-fact should you be injured in a car accident and become temporarily unconscious.
• There are five limitations on the authority of your attorney-in-fact:
  1. An attorney-in-fact has limited authority to order that life-sustaining treatment be withdrawn from you. Your attorney-in-fact may order that life-sustaining treatment be refused or withdrawn only if you have a terminal condition or if you are in a permanently unconscious state. And even then, the attending physician and, if applicable, the consulting physician must confirm that diagnosis and your attending physician(s) must determine that you have no reasonable possibility of regaining decision-making ability.
  2. Your attorney-in-fact does not have the authority to order the withdrawn of "comfort care." Comfort care is any type of medical or nursing care that would provide you with comfort or relief from pain.
  3. If you are pregnant, your attorney-in-fact cannot order the withdrawal of life-sustaining treatment unless certain conditions are met. Life-sustaining treatment cannot be withdrawn if doing so would terminate the pregnancy unless there is substantial risk to your life or two physicians determine that the fetus would not be born alive.
  4. Your attorney-in-fact may order that nutrition and hydration be withdrawn only if you are in a terminal condition or permanently unconscious state and two physicians agree that nutrition and hydration will no longer provide comfort or alleviate pain. If you want to give your attorney-in-fact the authority to withhold nutrition and hydration if you were to become permanently unconscious, you must indicate this in the appropriate section of the Health Care Power of Attorney form. If you also have a Living Will, it should be consistent with your Health Care Power of Attorney regarding the withholding of nutrition and hydration. In other words if you indicate in your Health Care Power of Attorney that it is permissible for your attorney-in-fact to order that nutrition and hydration be withheld, then you also should indicate in your Living Will that it is permissible for your physician to withhold nutrition and hydration.
  5. If you previously have given consent for treatment (before becoming unable to communicate), your attorney-in-fact cannot withdraw your consent unless certain conditions are met. Either your physical condition must have changed and/or the treatment you approved is no longer of benefit or the treatment has not been proven effective.
     
     

If you have a Health Care Power of Attorney and a Living Will, health care workers must go by the wishes you state in your Living Will, once the Living Will becomes effective. In other words, your Living Will takes precedence over your Health Care Power of Attorney.

You can change your mind and revoke your Health Care Power of Attorney at any time. You can do this simply by telling your attorney-in-fact, your physician and your family that you have changed your mind and wish to revoke your Health Care Power of Attorney. In this case, it is probably a good idea to ask for a copy of the document back from anyone to whom you may have given it.

How to fill out the Health Care Power of Attorney form:
You should use this form to appoint someone to make health care decisions for you if you should become unable to make them for yourself.

NOTE:

1. Read over all information carefully. Definitions are included as part of the form.
2. On the first two lines of the form, print your full name and birth date.
3. Under, "Naming of My Agent," fill in the name of the person you are appointing as your attorney-in-fact, the agent's current address and telephone number. You may name alternative agents on the indicated spaces following but do not need to do so. If you choose not to name alternative agents, you may wish to cross out the unused lines. You may not name your attending physician or the administrator of any nursing home where you are receiving care as your attorney-in-fact.
4. On the fifth page of the form, written in bold face type under Special Instructions is the statement that will give your physician permission to withhold food and water in the event you are permanently unconscious. If you want to give your physician permission to withhold food and water in this situation, then you must place your initials on the line indicated in number 3.
5. The form provides a section where you may write additional instructions and impose additional limitations that you may consider appropriate to document. You may attach additional pages if needed. You should include all attached pages with any copy(ies) you make and you should note the attached pages on the form itself in the related area.
6. Following "Additional Instructions or Limitations" is a section where you indicate whether or not you have a Living Will. Immediately below this area is where you date and sign the form. Remember, the Health Care Power of Attorney is not considered valid or effective unless you do one of the following:
   
   First Option - Date and sign the Health Care Power of Attorney in the presence of two witnesses, who also must sign and include their addresses and indicate the date of their signatures.
   
   OR
   
   Second Option - Date and sign the Health Care Power of Attorney in the presence of a notary public and have the Health Care Power of Attorney notarized on the appropriate space provided on the form.
   
   The following people may not serve as a witness to your Health Care Power of Attorney:
   The Agent and any successor agent named in this document;
   Anyone related to you by blood, marriage or adoption, including your spouse and your children;
   Your attending physician or, if you are in a nursing home, the administrator of the nursing home.

NOTE: The section titled NOTICE TO ADULT EXECUTING THIS DOCUMENT is required by law to be part of the document and must accompany it and its copies.