Medical power of attorney (POA)

Your Name*

First Middle Last

Designation of Primary Agent

Do you wish to have your spouse act as your primary agent?

Yes
No

If you are not married, please select “no”.

Provide the full name of your primary agent

First Middle Last

Primary agent address

Street Address Address Line 2 City State ZIP Code

Primary agent phone

Primary agent email address

Designation of Alternate Agents

Provide the full name of your first alternate agent

First Middle Last

First alternate agent address

Street Address Address Line 2 City State ZIP Code

First alternate agent phone

First alternate agent email address

Do you wish to identify a second alternate agent in your medical power of attorney?

Yes
No

Provide the full name of your second alternate agent

First Middle Last

Second alternate agent address

Street Address Address Line 2 City State ZIP Code

Second alternate agent phone

Second alternate agent email address

Quality of Life and Comfort Care

Would you like to provide specific instructions for your agent regarding your definition of "quality of life"?

Yes
No

For example, the power of attorney may include language such as: “My agent should bear in mind my standards for maintaining personal dignity and a meaningful quality of life. For me, quality of life requires/involves …”

Provide your definition of "quality of life" or any other standards you wish your agent to consider:

Select one or more of the following statements that describe your wishes

My agent may arrange for my transportation and long term care outside of the state in which I now reside
I do not want to become a burden to my family, or to impose upon them or intrude upon their households
I prefer to receive care in a hospice rather than in a hospital as the end of my life approaches
None of the above

Do you wish to identify certain people or items that you wish to have near you, or to provide that certain things be done for you, to provide additional comfort at the time of your death?

Yes
No

Please describe

Anatomical Gifts (Organ Donation)

You may choose to authorize the donation of your organs, tissue, bone, corneas, and other components of your body. If you desire to add this to your Medical Power of Attorney, please avoid any conflict with the organ donation instructions placed on your drivers’ license.

Do you wish to include instructions for anatomical gifts in your medical power of attorney?

Yes
No

Choose the statement(s) below which best describe your wishes.

My agent can make anatomical gifts on my behalf for the limited purpose of transplantation to such persons and organizations as my agent shall deem appropriate.
My agent can make anatomical gifts on my behalf for the limited purpose of transplantation to members of my immediate family.
My agent can make anatomical gifts on my behalf for use in medical research.
My agent is not authorized to make any anatomical gifts on my behalf.

Unless you select the fourth option, you may choose more than one.

Compensation of Agent

Agents are typically reimbursed for all reasonable expenses, and may be paid for the services rendered while acting as your agent.

Which of the following statements best describes your wishes?

I wish to reimburse reasonable expenses and provide reasonable compensation for services in fact provided by my agent.
I wish to reimburse reasonable expenses incurred by my agent.
I do not wish to reimburse either expenses or compensate for services provided by my agent.