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Instructions and Forms to Complete a Medical Power of Attorney

Follow these steps to complete a Medical Power of Attorney form.

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Step 1: Read the Disclosure Statement.

Get the Disclosure Statement form here:

      Or here:

Step 2: Fill out the Medical Power of Attorney form.

Get the Medical Power of Attorney form here:

Or Here

Remember to:

  • Complete the form in blue or black ink.
  • Name the person you would want to be your agent in the event of your incompetency.
  • Write any limitations on the decision-making authority of your agent that you want to include.
  • Name any alternate agents if your first choice cannot serve at the time of your incompetency.
  • Sign and date the form in front of a notary OR in front of two witnesses. Also have the notary or witnesses sign and date the form.
Step 3: Make copies for your agents and health care providers.

Keep the original and give a copy of the Medical Power of Attorney to your:

  • Agent,
  • Any alternate agents, and your
  • Health care and residential health care provider(s).

Providing these copies helps secure a smooth transition in the event you become incompetent.


Where can I get help filling out the form?

Get help filling out the form by talking with your:

  • Physician,
  • Health care provider,
  • Residential health care provider, or
  • Lawyer. 
Do I need a lawyer to help me?

You do not have to have a lawyer, but naming an agent in a power of attorney is an important decision and having legal help can be a good idea. If you decide that you need legal help, there are options. 

You can: