Blank Medical Power Of Attorney Form
Blank Medical Power Of Attorney Form – A Missouri medical power of attorney is a form that allows a trustee to appoint a representative to make health care decisions if he or she is unable to make health care decisions for themselves. It can also provide peace of mind knowing that a loved one who has your best interests at heart is empowered to make decisions when you are in a situation where you cannot communicate your wishes. In most cases, the principal will need a notary and two witnesses to attest to their signature on this document.
Download the form and review each point. The form can be easily downloaded as a PDF, Word or ODT file using the buttons on this page. You can complete Part I, which appoints someone to represent your interests, or Part II, which describes your medical treatment preferences, or you can complete both.
Blank Medical Power Of Attorney Form
Use the first blank line on this page to fill in the title of the document with the principal’s full name. Be sure to print the principal’s name clearly after the words “Print full name here”
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The director’s report should be continued with his full address. Use the space labeled “Address, City, State, Zip Code” to indicate the physical address of the principal’s residence.
The first section will provide the main declaration required by section 1 of the Enduring Power of Attorney for Health Care section. At the beginning, before the words “currently resident”, we will indicate the director’s full name.
Now look for the blank lines labeled “Name”, “Address and Phone(s)” in bold, which will apply to the listed attorney-in-fact. Enter the attorney-in-fact’s full legal name “Name” and the attorney-in-fact’s full residential address in the blank line labeled “Address”. Finally, the blank line titled “Phone(s”) lists two single spaces “1.” and “2.” so you can enter the actual attorney’s contact phone numbers. If the attorney-in-fact has only one phone number, enter it in the first field. Be sure to report everyone. Also, phone numbers are well maintained by the actual attorney.
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Item 2, titled “Alternate Agent,” deals with the idea of a backup agent. If desired, the principal may choose two persons to act as health care agent and to act as representative if that person is able or unable to act as health care agent. Enter the name, address, and phone number of the person who will exercise the power of attorney for health care.
In the “Primary Health Care Agent” and “First Alternate Agent” columns, enter the name, address, and telephone number(s) of the person who will act as a health care agent, whether qualified or unqualified to act as a health care agent . , in the “other alternative agent” column.
In point 4, we should address the “effective date as a health care decision maker.” By default, the health care options listed in this document will take effect when the principal is diagnosed in writing as unable to communicate or incompetent. If the power of attorney contained in this document can be made effective by a written diagnosis from a physician, check the first box. If an evaluation by two doctors will be necessary to actively establish authority in this document, check the second box in this paragraph.
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The fifth point will discuss the “power of the agent” and will need some information to explain it. First, we address whether the principal wishes to authorize the grantor to accept or refuse artificial feeding and hydration. If the principal intends to give the health care worker the right to refuse the principal’s artificial nutrition and hydration on his behalf, the principal must first check the box.
If the principal does not want to give the health care worker the authority to decide whether the principal should receive artificial nutrition and hydration, the principal must propose another certificate.
The elements listed in the following letter will mean a health care agent with the general duties that such an agency must perform. Clause B gives the agent the right to hire and fire medical professionals who care for the principal. Clause C authorizes the agent to give the principal power to determine where the principal receives (or does not receive) medical care. Subsection D authorizes the agent to enforce this document and provides immunity to those who comply. Atom designates the agent as the principal’s HIPAA representative. Any of these notices may be severed or deleted by the principal to prevent the agent from taking the actions described therein, but is advised to consult with an appropriate professional before doing so.
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Now in the “Effective Date as Other Entity” section, the director can decide what the health care agent can do outside of direct health care. If the settlor wants the attorney-in-fact to determine what happens to his body after death, the settlor must begin the first box in paragraph six.
If the principal gives the material for the autopsy of his body, the principal must start another column in this item.
The principal can grant the health care agent the principal right to delegate health care decision-making authority to another party (delegate), the principal must initiate the tin box.
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A fourth box must be initiated if the director agrees to the anatomical gift of his remains. If this box is launched, the following area should be visited directly. If the director has approved an anatomical gift from his or her own remains, you can specify the purpose for which the anatomical gift will be given. Look for the box that says “My donations are for the following,” then check the boxes to indicate what the Principal’s Anatomical Gift is for. The Director may specify the purpose(s) of transplantation, treatment, research, education, or all of the above. In the next box, you can indicate whether the grantor will donate any body parts as permitted by law by checking the first box after the words. If there are any restrictions, check the second box and document the restrictions in the space provided.
If the director does not wish to make anatomical gifts from his remains, he should check the box to the left of the “No Anatomical Gifts” label.
Part II is intended to directly address the principal’s specific instructions. In paragraph 2 of this section, the principal must initial the box corresponding to the statements explaining his instructions if he is diagnosed with a terminal illness/condition, disability, or without realistic hope of recovery. is permanently unconscious. . Each of the following medical interventions should be discontinued if they have a box associated with the main initiation. The director may select “artificial nutrition and hydration,” “surgery or other invasive procedures,” “cardiopulmonary resuscitation (CPR), antibiotics,” “dialysis,” “mechanical ventilator (respirator), chemotherapy, radiation therapy.”, and/or any “other procedures…” If the principal needs to describe a procedure or intervention not on this list, put it on a blank line after those words. Documentation can be done using “other methods specified by me (insert)”. The principal also has the option to prohibit “all other life-enhancing” medical or surgical procedures by simply checking the last box.
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Part III will begin with “The relationship between long-term healthcare mandates and healthcare directives.” Many of the statements labeled “A” through “D” will have some basic preferences that the principal motivates the agent to consider. The next three points deal with “the protection of third parties” who rely on the agent, “the creation of prior powers” and the “validity” of this directive. The principal may choose to remove any of these items and their components, but it is strongly recommended that you consult a doctor or lawyer before doing so. The principal should begin at the bottom of the third page.
Use two blank lines directly below the bold words “You must sign this document in the presence of two witnesses” to indicate the date you signed. The month and day of signing the document should be entered in the first field, and the year of signing should be entered in the second blank space.
The principal must then sign their name in the “Signature” line, then print their name in the “Printed Name” line.
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The “Witness” statement should include two separate boxes for each witness to sign and print their name, then write their address.
The last section is the “Notary’s Declaration” section, which the notary will have to fill in, following
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