Nursing Home Power of Attorney
I, [Your Name], residing at [Your Company Address], hereby appoint [Agent's Full Name] residing at [Agent's Address], as my attorney-in-fact to act on my behalf in all matters relating to my personal and health care decisions when I am unable to make those decisions for myself. This includes but is not limited to, decisions regarding my medical treatment, placement in a nursing home or assisted living facility, and management of my finances to pay for such care.
Effective Date
This Power of Attorney shall become effective immediately upon signing and shall remain in effect indefinitely unless revoked by me in writing.
Authority Granted
In exercising the powers granted under this Power of Attorney, my agent shall have the authority to:
Consent to or refuse medical treatment on my behalf, including surgery, medication, and other medical procedures.
Make decisions regarding my placement in a nursing home or assisted living facility, including selecting a specific facility and entering into agreements with such facilities.
Access my medical records and communicate with my healthcare providers to make informed decisions about my care.
Manage my finances to pay for my medical care and living expenses, including accessing my bank accounts, paying bills, and applying for government benefits.
Make decisions regarding my care and well-being, including housing arrangements, dietary needs, and daily activities.
Agent's Obligations
My agent shall act in my best interests and follow my wishes to the extent known. They shall exercise their powers diligently and prudently, considering all relevant factors and consulting with medical professionals and other relevant parties when necessary.
Limitations
This Power of Attorney does not authorize my agent to make decisions regarding my estate planning, including the creation or amendment of my will, trust, or other estate planning documents unless specifically authorized in a separate document.
Revocation
I reserve the right to revoke this Power of Attorney at any time by providing written notice to my agent. A revocation shall be effective upon delivery of the written notice to my agent.
In witness whereof, the Resident has executed this Nursing Home Power of Attorney on [Date].
[Your Name] (Principal)
[Agent's Name] (Attorney-in-fact)
WITNESS ACKNOWLEDGEMENT
I, [Witness's Name], affirm that I witnessed the signing of this Nursing Home Power of Attorney by the Resident and Attorney-in-Fact, who appeared to be of sound mind and voluntarily executed the same in my presence on [Date].
[Witness's Full Name]
NOTARY ACKNOWLEDGEMENT
On this [Date], before me, a Notary Public in and for the State and County aforesaid, personally appeared [Your Name] and [Agent's Name], known to me to be the persons described in and who executed the foregoing instrument, and acknowledged that they executed the same as their free and voluntary act and deed.
[Notary Public's Name]
My Commission Expires:
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