A Power of Attorney for My Health Care Page 4
Part 4: Do You Have Special Instructions or Limitations for Your Agent?
Use this space to add anything really
important that you want in this document. If
you need more space, attach a sheet to this
form. Consider using one of the resources
described in step 2 to help clarify and
communicate your wishes to your agent
Part 5: When Will This Power Be Effective?
Part 5 provides a very simple procedure for
making your Power of Attorney for Health
Care go into effect. Note that some states
have a required procedure for certifying
someone’s incapacity to make decisions,
and those provisions may override this
This Power of Attorney for My Health Care will become effective
during any time in which, in the opinion of my agent and
attending physician, I am unable to make or communicate a
choice about a particular health care decision.
Part 6: Other Provisions
These administrative provisions help
implement this document. Read them and
make sure you understand them.
Health care providers can rely on my agent. No one who
relies in good faith on any representations by my agent or
back-up agent will be liable to me, my estate, my heirs or
assigns, for recognizing the agent's authority.
I cancel any previous power of attorney for health care that I
may have signed.
I intend this power of attorney to be universal; it is valid in
any jurisdiction in which it is presented.
I intend that copies of this document are as effective as the
My agent will not be entitled to compensation for services
performed under this power of attorney, but he or she will be
entitled to reimbursement for all reasonable expenses that
result from carrying out any provision of this power of
Part 7: Sign Here
Sign and date this form in front of two
witnesses who meet the qualifications listed
on the next page and who actually see you
sign the document. The list of people who
should NOT be your witness is long
because it represents all of the different
Four states require that the form be
notarized and witnessed: Missouri, North
Carolina, South Carolina, and West
I understand the contents of this document and the effect of
granting powers to my agent.
My signature _______________________________________________
My printed name _______________________________________________
First Middle Last
Month / Day / Year