Health Care Power of Attorney Forms: Examples and Sample Wording

Health Care Power of Attorney Basics

Simply put, this document allows you to designate someone to be your personal representative if you are unable to make or communicate health care decisions. They might also be called a “health care agent.”

As you are exploring how to put your estate planning wishes into legally binding documents, you may notice some of the language is hard to understand. Attorneys are mindful of using precise language and always following the law in your state — but you also want to understand what you are agreeing to.

Health Care Power of Attorney: Form Language

Below you will find sample language to help you understand your health care power of attorney. This legal document uses very precise language to explain your health care agent’s authority, what power your health care providers have, who has decision-making rights, and more.

Legal language can be difficult to understand at times but it needs to be very precise to make sure your wishes are clearly conveyed and comply with the law. Even if family members want to step in to make choices about your mental health, health care facility, organ donation, etc. they must follow what your POA document says. The person you chose to act as your POA ensures your document is followed.

Example 1: Naming Your POA

You may find language like “I, _______, make, constitute and appoint _______.” This is simply various ways to say you choose a certain person as your POA.

Typically once you name the person one time in the document, you will find language that says “hereinafter referred to as my ‘Health Care Representative’” and their name will not be used again.

Example 2: Giving Your POA Power

It is common to find language declaring the power your new POA has. This often sounds like “my true and lawful attorney-in-fact… to be my Health Care Representative.” Their powers are often broadly described as something like “with respect to all health care matters, upon the terms and conditions hereinafter set forth.”

From this point, the forms will go into more detail about the exact powers they have. You may see phrases or sentences like:

• “I do not wish to receive futile medical treatment”
• “Do not prolong my inevitable death or irreversible coma”
• “I desire that my wishes… be carried out … despite any contrary feelings, beliefs or opinions of other members of my family, relatives or friends”

Example 3: Giving Your Physician Power

You can give your POA complete power with a phrase like “…but in no way to limit the absolute authority and discretion granted herein to my Health Care Representative.”

You can also create your POA document in a way that limits the power of your chosen POA caretaker. This language may sound like “in order to aid my Health Care Representative in making decisions under this Health Care Power of Attorney…”

From there, the document may list the situations where a physician should be consulted. You might see wording like:

• “Two licensed physicians who are familiar with my condition have diagnosed and noted in my medical records…”
• Two licensed physicians declare I am in the terminal stage of an irreversibly fatal illness, disease or condition”
• “My chosen physician determined my condition is expected to result in my death within six (6) months or less regardless of what medical treatment I may receive”
• “Two licensed physicians who are familiar with my condition have diagnosed and noted in my medical records that I am permanently unconscious”
• “Two licensed physicians who are familiar with my condition have determined that my life may only be maintained by artificial means, including, but not limited to, respirators and feeding tubes”
• “Two licensed physicians declare there is no reasonable possibility that I will ever be able to sustain my life without such artificial means”

Example 4: Determining Medical Actions

A health care power of attorney document may spell out your wishes and exact medical procedures. In other cases, this might be listed in a living will or health care directive document instead. It is common to have the information in both places.

It may start with language like “my Health Care Representative is authorized to do any one or more of the following…”

In greater detail, your wishes may be spelled out with phrases such as:

• “To sign on my behalf”
• “To give or withhold consent to any medical care or treatment”
• “To revoke or change any consent previously given or implied by law”
• “To arrange for my placement in or removal from any hospital, convalescent home, or other health care institution”
• “Require that such treatment as cardiopulmonary resuscitation, surgery, dialysis, the use of a respirator, blood transfusion, antibiotics, antiarrhythmic, and pressure drugs, or transplants) not be instituted”
• “If treatment was previously instituted, I require that it be discontinued”
• “To authorize the administration of pain-relieving drugs even if they may shorten my remaining life”

Example 5: Unlimited Actions and Power

It is common to see complex language that simply limits your POA’s power. This might sound like “The rights and authority conferred on my Health Care Representative herein appointed shall include…”

If you want to give unlimited power to your health care agent, it might say “but is by no means limited to…” with more details. Using this phrasing helps give unlimited power because no document can ever cover every single issue that might come up.

Giving power like this can help cover all people and situations:

• All treating physicians
• Other health care professionals
• Various health care institutions
• Proposed health care
• Proposed surgery
• Any other aspect of medical treatment
• Hiring or firing medical, social service, or other support personnel

Your document will also include legal language that stops your POA from taking on personal financial liability.

Example 6: Covering All Legal Terms

You may see language that says “… is to be construed and interpreted as…” or “as such term is defined in [state statute ].” Once a term is defined one time, the document might say a shorter name or term will be used. This may look like “hereinafter the “Act”.”

It is also common to see broad legal terms such as:

• “In good faith”
• “Upon any representations”
• “Any successor”
• “Binding in all respects”
• “Entitled to indemnification”
• “From my estate”

Example 7: Administrative Information

A section of your POA document needs to cover basic administrative information and tasks. This includes timing, removing the POA, paying the person acting as your POA, how to handle issues, and where the POA is legally binding.

These may include or sound like:

• “I hereby revoke any prior Health Care Power of Attorney”
• “This POA is intended to be valid in any jurisdiction in which it is presented”
• “My Health Care Representative shall/shall not be entitled to compensation for services performed under this POA”
• “My representative shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provisions of this POA”
• “It is my wish and desire that such disagreement be resolved in accordance with…”
• “By this instrument, I intend to create a durable power of attorney…”
• “This is effective upon and only during any period of…”
• “The rights, powers, and authority of my Health Care Representative herein appointed shall commence and shall be in full force and effect upon…”
• “Such rights, powers, and authority shall remain in full force and effect from the above-mentioned date until such time as…”
• “This Health Care Power of Attorney may be revoked by me by a written instrument duly acknowledged before a notary public or by such other manner as shall be allowed under the Act”
• “My regaining capacity following any Period of Incapacity shall not be treated as an event causing the revocation of this Health Care Power of Attorney”

Example 8: Signing The Document

Some of the final wording in your POA document will be about signing it. This is what makes it legally binding as long as you followed the requirements in your state.

It may say, “I understand the purpose and effect of this POA” followed by “I sign it after careful deliberation.” This section also needs to include the date and your printed name or initials.

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Example 9: Witnesses and Notaries

If others need to be present for the document signing, such as your chosen POA or notaries, they will have a section as well. They are typically referred to as “the undersigned” in the document because they sign below your signature.

It may sound like “each of the undersigned declares…” and “the person who signed this Health Care Power of Attorney did so in the presence of the undersigned.”

They will also need to explain that they are legal adults. It may say something like “each of the undersigned and the person executing this Health Care POA is 18 years of age or older.”

Lastly, if they serve as a legal witness, you may see terms like:

• “They personally came before me”
• “Acknowledged under oath”
• “To my satisfaction that they are the person named in…”
• “They signed, sealed, and delivered this Health Care Power of Attorney”
• “As their act and deed for the uses and purposes therein expressed”

Example 10: Sound Mind

The witnesses or notaries of your POA often have to swear that you are of “sound mind” at the time. This typically sounds like “…that said person is personally known to the undersigned and appears to be of sound mind and acting willingly and free from duress or undue influence.”

Need Additional Help With a Power of Attorney?

Health care powers of attorney require careful consideration. They should clearly express your desires while also obeying the procedural requirements of your state. You can create state-specific living will forms online and follow specific directions to make them legally binding.

If you feel you need more help, contact a local estate planning attorney to learn how they can help you prepare documents to direct doctors in case of an unexpected crisis.