Practice Areas : Legal Documents : Health Care Power of Attorney

A Health Care Power of Attorney is a document that allows you to designate an agent who will have the authority to make health care decisions on your behalf if you become unconscious, mentally incompetent, or otherwise unable to make such decisions.

Your Personal Information

* Full Legal Name:

* Address:

* City:

* Zip Code:

* County:

* Telephone Number:

* Email Address:

* Date of Birth:

Name of Agent

The person named below is my agent who will make health care decisions for me as authorized in the document.

My Agent:

* Full Legal Name:

* Address:

* City:

* Zip:

* County:

* Telephone Number:

Alternate Agents

The person named below is the primary alternate agent. Note, alternate agents are not required to complete this document.

Alternate Agent #1:

Full Legal Name:

Address:

City:

Zip:

County:

Telephone Number:

The person named below is the secondary alternate agent. Note, alternate agents are not required to complete this document.

Alternate Agent #2:

Full Legal Name:

Address:

City:

Zip:

County:

Telephone Number:

Additional Instructions

I may give additional instructions or impose additional limitations on the authority of my agent. You may wish to leave this field blank and manually attach separate pages to the printed version if you feel you will need more space. If you have no additional instructions, you may wish to write "None".

Additional Instructions:

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