Blank Medical Power of Attorney Template for North Carolina
Contents
In the realm of healthcare decision-making, the North Carolina Medical Power of Attorney form stands as a vital tool for individuals seeking to ensure their medical preferences are honored when they are unable to communicate those wishes themselves. This legally binding document empowers a designated agent to make medical decisions on behalf of the individual, thereby providing clarity and direction during challenging times. The form encompasses critical elements, such as the appointment of the agent, the scope of authority granted, and any specific instructions regarding medical treatment preferences. Additionally, it is essential to understand the importance of selecting a trustworthy and capable agent, as this person will be responsible for making decisions that align with the individual’s values and desires. Furthermore, the North Carolina Medical Power of Attorney form allows for the inclusion of advance directives, which can guide the agent in making choices related to life-sustaining treatments and end-of-life care. By completing this form, individuals take proactive steps to safeguard their healthcare wishes, ensuring their voice is heard even in moments of vulnerability.
Sample - North Carolina Medical Power of Attorney Form
North Carolina Medical Power of Attorney
This Medical Power of Attorney is established according to the North Carolina Health Care Power of Attorney Act (N.C. Gen. Stat. § 32A-15 to 32A-26). It grants authority to a designated person to make medical decisions on behalf of the principal when they are unable to do so themselves.
Principal Information:
- Full Name: ___________________________
- Address: _____________________________
- City: ________________________________
- State: North Carolina
- Zip Code: ____________________________
- Date of Birth: _______________________
- Social Security Number: _______________
Designated Health Care Agent Information:
- Full Name: ___________________________
- Relationship to Principal: ____________
- Primary Phone: ________________________
- Alternate Phone: ______________________
- Email Address: ________________________
Authority Granted: The principal designates the above-named Health Care Agent the authority to:
- Make any and all health care decisions on the principal's behalf when the principal is not capable of making informed decisions.
- Access the principal's medical records necessary for making informed decisions about the principal's health care.
- Communicate with health care providers about the principal's condition, treatment plan, and prognosis.
- Give or withhold consent for medical treatments, procedures, and interventions, except where limited by this document.
- Make decisions about the principal's admission or discharge from health care facilities, including hospitals, rehabilitation centers, and long-term care facilities.
Limitations on Health Care Agent's Authority (if any): _______________________________________
Alternative Health Care Agent (optional):
- Full Name: ___________________________
- Relationship to Principal: ____________
- Primary Phone: ________________________
- Alternate Phone: ______________________
- Email Address: ________________________
This Medical Power of Attorney becomes effective when the principal is determined to be unable to make or communicate health care decisions by:
- The attending physician and another physician or licensed psychologist.
Signature of Principal: _______________________________ Date: _____________
Witness (1) Signature: _______________________________ Date: _____________
Printed Name: ________________________________________
Witness (2) Signature: _______________________________ Date: _____________
Printed Name: ________________________________________
This document was signed in the presence of both witnesses, who are not related to the principal by blood or marriage and are not beneficiaries of the principal's estate.
File Specs
| Fact Name | Description |
|---|---|
| Purpose | The North Carolina Medical Power of Attorney form allows individuals to designate someone to make healthcare decisions on their behalf if they become unable to do so. |
| Governing Law | This form is governed by North Carolina General Statutes Chapter 32A. |
| Eligibility | Any adult who is of sound mind can create a Medical Power of Attorney in North Carolina. |
| Agent Selection | The individual can choose any competent adult as their agent, but it is advisable to select someone who understands their healthcare preferences. |
| Signature Requirement | The form must be signed by the principal (the person granting authority) in the presence of two witnesses or a notary public. |
| Revocation | The principal can revoke the Medical Power of Attorney at any time, as long as they are mentally competent. |
| Healthcare Provider Notification | Healthcare providers must be notified of the existence of the Medical Power of Attorney to ensure the agent's authority is recognized. |
| Limitations | The agent cannot make decisions regarding the principal's mental health treatment unless specifically authorized in the document. |
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