North Carolina Medical Power of Attorney
This Medical Power of Attorney is designed to comply with North Carolina General Statutes, Chapter 32A. It allows you to designate someone to make medical decisions on your behalf if you become unable to do so.
Please fill in the blanks with your information where indicated.
Principal's Information:
- Name: ____________________________________
- Address: ___________________________________
- City, State, Zip: ___________________________
- Date of Birth: ______________________________
Agent's Information:
- Name: ____________________________________
- Address: ___________________________________
- City, State, Zip: ___________________________
- Phone Number: ______________________________
Effective Date: This Medical Power of Attorney becomes effective when I am unable to make my own health care decisions.
Limitations: You may specify any limitations on the authority granted to your agent here:
__________________________________________________________
__________________________________________________________
Health Care Decisions: My agent shall have the authority to make decisions regarding my medical treatment, including:
- Consent to or refuse medical treatment.
- Access to my medical records.
- Make decisions about life-sustaining treatment.
Signature:
I, the undersigned, hereby appoint the above-named agent as my Medical Power of Attorney.
Signature: ____________________________________
Date: ________________________________________
Witnesses: This document must be signed in the presence of two witnesses who are not related to you or your agent.
- Witness 1 Name: ____________________________
- Witness 1 Signature: ________________________
- Witness 2 Name: ____________________________
- Witness 2 Signature: ________________________
This document should be kept in a safe place and copies should be provided to your agent and healthcare providers.