North Carolina Statutory Power of Attorney
I, [Your Name], residing at [Your Address], in the county of [Your County], state of North Carolina, do hereby appoint [Agent's Name] of [Agent's Name], as my lawful Attorney-in-fact, to act in my name, place, and stead in all capacities to make healthcare decisions for me to the extent that I could do if personally present.
Effective Date
This power shall become effective on the date of [Date] and shall not be affected by my subsequent disability or incompetence.
Scope of Authority
Medical Treatment Decisions: The Agent is authorized to make decisions regarding medical treatments, including but not limited to surgeries, medications, and therapies, based on the Agent's understanding of my preferences and best interests.
End-of-Life Decisions: The Agent is empowered to make decisions regarding life-sustaining treatments, including the withholding or withdrawal of such treatments, under my wishes as expressed in this document or as otherwise known to the Agent.
Choice of Healthcare Providers: The Agent may select healthcare providers, hospitals, clinics, or other medical facilities for my care, taking into consideration the quality of care provided and the compatibility with my preferences.
Access to Medical Information: The Agent shall have full access to my medical records, including but not limited to diagnoses, treatment plans, and test results, and may disclose such information to healthcare providers as necessary for the provision of healthcare services.
Communication with Healthcare Professionals: The Agent is authorized to communicate with healthcare professionals, including physicians, nurses, and other caregivers, on my behalf, to discuss treatment options, obtain medical opinions, and provide or withdraw consent for medical procedures.
Limitations
This Power of Attorney specifically excludes the authority to make decisions regarding mental health treatment, unless such authority is explicitly granted in a separate document.
Duration of Authority
This Power of Attorney shall remain in effect indefinitely unless revoked by me or until my death.
Signature
In witness whereof, I have hereunto set my hand and seal this [Day] day of [Month, Year].
[Your Name]
[Date Signed]
[Agent's Name]
[Date Signed]
Witness Acknowledgement
We, the undersigned witnesses, certify that the Principal signed or acknowledged this Power of Attorney in our presence, that the Principal appeared to be of sound mind and under no duress, and that the Principal signed willingly.
Witness 1:
[Witness 1: Full Name]
[Date Signed]
Witness 2:
[Witness 2: Full Name]
[Date Signed]
Notary Acknowledgement
State of North Carolina County of [County]
On this [Day] day of [Month, Year], before me, the undersigned notary public, personally appeared [Your Name], known to me to be the person whose name is subscribed to the preceding instrument, and acknowledged that he/she executed the same for the purposes therein contained.
Witness my hand and official seal:
[Notary Public's Name]
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