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.
