Hospital Power of Attorney
This document, made this [DATE], appoints [ATTORNEY-IN-FACT'S NAME] of [ATTORNEY-IN-FACT'S ADDRESS] as the Attorney-in-fact for [YOUR NAME] residing at [YOUR COMPANY ADDRESS] granting Power of Attorney for medical decisions.
I. Appointment of Attorney-In-Fact
I, [YOUR NAME], appoint [ATTORNEY-IN-FACT'S NAME] as my Attorney-In-Fact (also referred to as "Agent").
II. Powers of Attorney-In-Fact
I grant my Attorney-In-Fact the power to make decisions regarding my medical treatment and care including, but not limited to, decisions relating to surgery, selection of healthcare providers, medication, and all other matters affecting my health if I become incapable of making those decisions myself.
Decision-Making Authority: The agent shall have the authority to make all healthcare decisions on behalf of the principal, specifically related to surgical procedures, in the event the principal is unable to do so themselves due to incapacity or unconsciousness.
Consultation with Medical Professionals: The agent shall consult with attending physicians, surgeons, and other healthcare providers to gather information about the principal's medical condition, treatment options, and prognosis, to make informed decisions.
Consent for Surgical Procedures: The agent shall have the authority to provide consent for surgical procedures on behalf of the principal, including but not limited to, decisions regarding the necessity of surgery, choice of surgical methods, and post-operative care.
Treatment Decisions in Case of Complications: In the event of complications arising during or after surgery, the agent shall have the authority to make decisions regarding additional medical interventions, follow-up procedures, and any necessary adjustments to the treatment plan.
Communication with Family Members: The agent shall communicate with the principal's family members, informing them of the principal's medical condition, treatment options, and decisions made regarding surgical procedures and related healthcare matters.
III. Governing Law
This document will be governed by the laws of the state of [STATE].
By signing below, I affirm that I am of sound mind and understand the nature and effect of this document.
[Your Name](Principal)
[DATE]
[ATTORNEY-IN-FACT'S NAME](Agent)
[DATE]
Witness Acknowledgement
We, the undersigned witnesses, hereby acknowledge that the principal has executed this Hospital Power of Attorney in our presence, and we affirm that the principal appears to be of sound mind and under no duress or undue influence.
[Witness Name][Witness 1]
[DATE]
[Witness Name][Witness 2]
[DATE]
Notary Acknowledgement
On this day of in the year , before me, a Notary Public in and for said County and State, personally appeared [Your Name], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that they executed the same for the purposes therein contained.
Witness my hand and official seal.
[Notary Public Name]
[DATE]
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