General Medical Power of Attorney Form 2General Medical Power of Attorney Form 2General Medical Power of Attorney Form 2
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Medical Power of Attorney
Effective Upon Execution
I, [NAME], a resident of [ADDRESS. COUNTY, STATE];
Social Security Number [NUMBER] designate [NAME],
presently residing at [ADDRESS], telephone number
[PHONE NUMBER] as my agent to make any and all health
care decisions for me, except to the extent I state otherwise
in this document. For the purposes of this document, "health
care decision" means consent, refusal of consent, or
withdrawal of consent to any care, treatment, service, or
procedure to maintain, diagnose, or treat an individual's
physical or mental condition. This medical power of attorney
takes effect if I become unable to make my own health care
decisions and this fact is certified in writing by my physician.
Limitations: [Describe any desired limitations, for example,
concerning life support, life-prolonging care, treatment,
services, and procedures.]
Inspection and Disclosure of Information Relating to My
Physical or Mental Health: Subject to any limitations in this
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