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Enter the full legal name of this person as it would appear on a legal document.
Enter the full legal name of this person as it would appear on a legal document.
A Healthcare Proxy (Medical Power of Attorney) designates a trusted person to make medical decisions on your behalf if you are unconscious, mentally incapacitated, or otherwise unable to communicate your wishes. Different from a Living Will, which records your preferences — the healthcare proxy authorizes a specific person to exercise judgment when your written directive doesn't cover a situation. Fill out this free healthcare proxy template online, e-sign it digitally, and download a legally valid PDF. no account or lawyer needed. Sections: Principal, Healthcare Agent.
I, ______________, of ______________, hereby appoint ______________ (phone: ______________) as my healthcare agent.
My agent has full authority to make any and all healthcare decisions on my behalf, including consenting to or refusing medical treatment, when I am unable to make such decisions myself, as determined by my attending physician.
If my primary agent is unavailable or unwilling to serve, I appoint no alternate as my alternate healthcare agent.
My agent is authorized to receive protected health information under HIPAA and any applicable state privacy laws.
This Healthcare Proxy is governed by the laws of the State of ______________.